Comprehensive Analysis of Left Ventricular Geometry and Function by Three-Dimensional Echocardiography in Healthy Adults

Echocardiographic assessment of left ventricular volumes: a comparison of different methods in athletes

BACKGROUND

Cardiac magnetic resonance imaging (cMRI) is considered the gold standard for the assessment of left ventricular (LV) systolic function. However, discrepancies have been reported in the literature between LV volumes assessed by transthoracic echocardiography (TTE) and cMRI. The objective of this study was to analyze the differences in LV volumes between different echocardiographic techniques and cMRI.

METHODS AND RESULTS

In 64 male athletes (21.1 ± 4.9 years), LV volumes were measured by TTE using the following methods: Doppler echocardiography, anatomical M-Mode, biplane/triplane planimetry and 3D volumetry. In addition, LV end-diastolic (LVEDV), end-systolic (LVESV), and stroke volumes (LVSV) were assessed in 11 athletes by both TTE and cMRI. There was no significant difference between LVEDV and LVESV determined by biplane/triplane planimetry and 3D volumetry. LVEDV and LVESV measured by M-Mode were significantly lower compared to 3D volumetry. LVSV determined by Doppler with 3D planimetry of LV outflow tract was significantly higher than 2D planimetry and 3D volumetry, whereas none of the planimetric or volumetric methods for determining LVSV differed significantly. There were no significant differences for LVEDV, LVESV, LVSV and LVEF between cMRI and TTE determined by biplane planimetry in the subgroup of 11 athletes.

CONCLUSION

The choice of echocardiographic method used has an impact on LVSV in athletes, so the LVSV should always be checked for plausibility. The same echocardiographic method should be used to assess LVSV at follow-ups to ensure good comparability. The data suggest that biplane LV planimetry by TTE is not inferior to cMRI.

Sex differences in left atrial volumes, mechanics, and stiffness in primary mitral regurgitation-a combined 2D and 3D echocardiographic study

AIMS

Mitral regurgitation (MR) causes left atrial (LA) enlargement and impaired reservoir function. We assessed whether changes in LA size, strain, and stiffness in significant (moderate or greater) primary MR are sex-specific.

METHODS AND RESULTS

In the 3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation study, 111 patients with primary MR were prospectively investigated with 2D and 3D echocardiography. MR was severe if the 3D regurgitant fraction was ≥50%. LA size was assessed by maximum, minimum, and pre-A 3D volume (LAV), mechanics by peak reservoir (LASr) and contractile strain, and stiffness by the ratio: mitral peak E-wave divided by the annular e' velocity (E/e')/LASr. Women were older, had higher heart rate, and lower body mass index and MR regurgitant volumes (P < 0.05). 3D LAV indexed for body surface area and LA contractile strain did not differ by sex, while LASr was lower (22.2 vs. 25.0%) and LA stiffness higher in women (0.56 vs. 0.44) (P < 0.05). In linear regression analysis, female sex was associated with higher LA stiffness independent of age, minimum LAV, left ventricular global longitudinal strain, diabetes, and coronary artery disease (R2 = 0.56, all P < 0.05). In logistic regression analysis, women had a four-fold (95% CI 1.2-13.1, P = 0.02) higher adjusted risk of increased LA stiffness than men.

CONCLUSION

Women with significant primary MR have more impaired LA reservoir mechanics and increased LA stiffness compared with men despite lower MR regurgitant volumes and similar indexed LA size. The findings reveal sex-specific features of LA remodeling in MR.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04442828.

Echocardiographic Measurements in Normal Chinese Adults (EMINCA) II focusing on left ventricular and left atrial size and function by three-dimensional echocardiography

Current guidelines encourage large studies in a diverse population to establish normal reference ranges for three-dimensional (3D) echocardiography for different ethnic groups. This study was designed to establish the normal values of 3D-left ventricular (LV) and left atrial (LA) volume and function in a nationwide, population-based cohort of healthy Han Chinese adults. A total of 1117 healthy volunteers aged 18-89 years were enrolled from 28 collaborating laboratories in China. Two sets of 3D echocardiographic instruments were used, and full-volume echocardiographic images were recorded and transmitted to a core laboratory for image analysis with a vendor-independent off-line workstation. Finally, 866 volunteers (mean age of 48.4 years, 402 men) were qualified for final analysis. Most parameters exhibited substantial differences between different sex and age groups, even after indexation by body surface area. The normal ranges of 3D-LV and 3D-LA volume and function differed from those recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, presented by the World Alliance Societies of Echocardiography (WASE) study, and from the 2D values in the EMINCA study. The normal reference values of 3D echocardiography-derived LV and LA volume and function were established for the first time in healthy Han Chinese adults. Normal ranges of 3D-LV and 3D-LA echocardiographic measurements stratified with sex, age, and race should be recommended for clinical applications.

Super-resolution Left Ventricular Flow and Pressure Mapping by Navier-Stokes-Informed Neural Networks

Intraventricular vector flow mapping (VFM) is a growingly adopted echocardiographic modality that derives time-resolved two-dimensional flow maps in the left ventricle (LV) from color-Doppler sequences. Current VFM models rely on kinematic constraints arising from planar flow incompressibility. However, these models are not informed by crucial information about flow physics; most notably the pressure and shear forces within the fluid and the resulting accelerations. This limitation has rendered VFM unable to combine information from different time frames in an acquisition sequence or derive fluctuating pressure maps. In this study, we leveraged recent advances in artificial intelligence (AI) to develop AI-VFM, a vector flow mapping modality that uses physics-informed neural networks (PINNs) encoding mass conservation and momentum balance inside the LV, and no-slip boundary conditions at the LV endocardium. AI-VFM recovers the flow and pressure fields in the LV from standard echocardiographic scans. It performs phase unwrapping and recovers flow data in areas without input color-Doppler data. AI-VFM also recovers complete flow maps at time points without color-Doppler input data, producing super-resolution flow maps. We show that informing the PINNs with momentum balance is essential to achieving temporal super-resolution and significantly increases the accuracy of AI-VFM compared to informing the PINNs only with mass conservation. AI-VFM is solely informed by each patient's flow physics; it does not utilize explicit smoothness constraints or incorporate data from other patients or flow models. AI-VFM takes 15 minutes to run in off-the-shelf graphics processing units and its underlying PINN framework could be extended to map other flow-associated metrics like blood residence time or the concentration of coagulation species.

Clinical Impact of the Volumetric Quantification of Ventricular Secondary Mitral Regurgitation by Three-Dimensional Echocardiography

BACKGROUND

The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients.

METHODS

We included 229 patients (70 ± 13 years, 74% men) with v-SMR. We compared EROA and RegVol calculated by the 3DEVM, 2DEVM, and PISA methods. The end point was a composite of heart failure hospitalization and death for any cause.

RESULTS

After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm2 (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001).

CONCLUSIONS

Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.

Timing of Surgery for Asymptomatic Primary Mitral Regurgitation: Possible Value of Early, Serial Measurements of Left Ventricular Sphericity

Asymptomatic primary mitral regurgitation due to myxomatous degeneration of the mitral valve leaflets may remain so for long periods, even as left ventricular function progresses to a decompensated stage. During the early compensated stage, the ventricle's initial response to the volume overload is an asymmetric increase in the diastolic short axis dimension, accomplished by a diastolic shift of the interventricular septum into the right ventricular cavity, creating a more spherical left ventricular diastolic shape, increasing diastolic filling and stroke volume. Early valve repair is recommended to reduce postoperative left ventricular dysfunction. Early serial measurements of left ventricular sphericity index [LV-Si]. during the compensated stage of mitral regurgitation might identify subtle changes in left ventricular shape and assist in determining the optimal earliest timing for surgical intervention.

Normalized Echocardiographic Values From Guideline-Directed Dedicated Views for Cardiac Dimensions and Left Ventricular Function

BACKGROUND

Continuous technologic development and updated recommendations for image acquisitions creates a need to update the current normal reference ranges for echocardiography. The best method of indexing cardiac volumes is unknown.

OBJECTIVES

The authors used 2- and 3-dimensional echocardiographic data from a large cohort of healthy individuals to provide updated normal reference data for dimensions and volumes of the cardiac chambers as well as central Doppler measurements.

METHODS

In the fourth wave of the HUNT (Trøndelag Health) study in Norway 2,462 individuals underwent comprehensive echocardiography. Of these, 1,412 (55.8% women) were classified as normal and formed the basis for updated normal reference ranges. Volumetric measures were indexed to body surface area and height in powers of 1 to 3.

RESULTS

Normal reference data for echocardiographic dimensions, volumes, and Doppler measurements were presented according to sex and age. Left ventricular ejection fraction had lower normal limits of 50.8% for women and 49.6% for men. According to sex-specific age groups, the upper normal limits for left atrial end-systolic volume indexed to body surface area ranged from 44 mL/m2 to 53 mL/m2, and the corresponding upper normal limit for right ventricular basal dimension ranged from 43 mm to 53 mm. Indexing to height raised to the power of 3 accounted for more of the variation between sexes than indexing to body surface area.

CONCLUSIONS

The authors present updated normal reference values for a wide range of echocardiographic measures of both left- and right-side ventricular and atrial size and function from a large healthy population with a wide age-span. The higher upper normal limits for left atrial volume and right ventricular dimension highlight the importance of updating reference ranges accordingly following refinement of echocardiographic methods.

Three-Dimensional-Derived Echocardiographic Left Ventricular Structure and Function and Indices from the 12-Lead Electrocardiogram across the Menstrual Cycle in Healthy Physically Active Females: An Exploratory Study

Background: The impact of the menstrual phases on left ventricular (LV) structure and function using 3D echocardiography and resting electrocardiogram (ECG) in healthy, eumenorrheic, and physically active females has not been investigated. Methods: sixteen females (20 y ± 2) underwent 3D echocardiography and an ECG at three time points in the menstrual cycle phases (follicular, ovulation, luteal). LV end-diastolic volume (LVEDVi), LV ejection fraction (LVEF), LV mass allometrically indexed to height2.7 (LVMi), torsion, and global longitudinal, circumferential, and radial strain (GLS, GCS, and GRS) were evaluated. ECG data of the P and QRS waves were presented as well as axis deviation, chamber enlargement, and any rhythm abnormalities. Results: LVMi was significantly higher in the luteal phase (36.4 g/m2.7 ± 3.3) compared to the follicular (35.0 g/m2.7 ± 3.7) and ovulation (34.7 g/m2.7 ± 4.3) phases (p = 0.026). There were no differences in other indices of LV structure and function or ECG variables across all phases of the menstrual cycle or evidence of arrhythmia. Conclusions: In physically active females, there is a small but significantly higher LVMi associated with the luteal phase of the menstrual cycle with no concomitant change in LV function or ECG parameters. These findings are important to consider when conducting clinical or research serial assessments.

Left ventricular remodeling in rheumatoid arthritis patients without clinical heart failure

Rheumatoid arthritis (RA) patients have a 1.5- to twofold higher risk of developing heart failure (HF) and a twofold increased risk of HF-associated mortality compared to those without RA. HF is preceded subclinically by left ventricular (LV) remodeling in the general population. There is a relative absence of prospective studies following RA patients from pre-clinical to clinical HF as well as prospective studies of LV remodeling in RA without clinical HF. In our study, 158 RA patients without clinical HF were enrolled and underwent transthoracic echocardiography (TTE) at baseline and on follow-up between 4 and 6 years. Extensive characterization of RA disease activity and cardiovascular risk factors were performed. LV remodeling was prevalent at 40% at baseline and increased to 60% over time. Higher levels of interleukin-6 (IL 6) were associated with concentric LV remodeling on follow-up. The use of tocilizumab was also significantly associated with baseline LV remodeling (relative wall thickness). These findings suggest a role for IL-6 as a biomarker for LV remodeling in RA patients without clinical HF. Future research should focus on prospective follow-up of LV remodeling and the effects of IL-6 inhibition on LV remodeling in RA patients.

Valid and Reproducible Quantitative Assessment of Cardiac Volumes by Echocardiography in Patients with Valvular Heart Diseases-Possible or Wishful Thinking?

The analysis of left ventricular function is predominantly based on left ventricular volume assessment. Especially in valvular heart diseases, the quantitative assessment of total and effective stroke volumes as well as regurgitant volumes is necessary for a quantitative approach to determine regurgitant volumes and regurgitant fraction. In the literature, there is an ongoing discussion about differences between cardiac volumes estimated by echocardiography and cardiac magnetic resonance tomography. This viewpoint focuses on the feasibility to assess comparable cardiac volumes with both modalities. The former underestimation of cardiac volumes determined by 2D and 3D echocardiography is presumably explained by methodological and technical limitations. Thus, this viewpoint aims to stimulate an urgent and critical rethinking of the echocardiographic assessment of patients with valvular heart diseases, especially valvular regurgitations, because the actual integrative approach might be too error prone to be continued in this form. It should be replaced or supplemented by a definitive quantitative approach. Valid quantitative assessment by echocardiography is feasible once echocardiography and data analysis are performed with methodological and technical considerations in mind. Unfortunately, implementation of this approach cannot generally be considered for real-world conditions.

Myocardial work-A new tool for early detection of rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone chemotherapy induced-cardiotoxicity in hematological patients

BACKGROUND

Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (RCHOP) chemotherapy in non-Hodgkin's lymphoma (NHL) has risk of cardiotoxicity.

PURPOSE

To determine the role of myocardial work and biomarkers in subclinical diagnosis and prediction of cardiotoxicity.

METHODS

The 130 NHL patients (52 ± 9 years, 62% men) scheduled for RCHOP, with LVEF>50%, were evaluated at baseline, after third cycle and chemotherapy completion for 3D LVEF, 2D myocardial deformation (longitudinal, radial, circumferential strain - LS, RS, CS) and myocardial work (global constructive work, waste work, work index and work efficiency - GCW, GWW, GWI, GWE). NT-pro-BNP and troponin I were determined.

RESULTS

After chemotherapy ended, 37 patients (28%) (group I) developed asymptomatic cardiotoxicity (8 mild form, 25 moderate form, 4 severe form); 93 patients (group II) did not. After third cycle, all patients had decreased LS, CS, RS, GCW, GWI, GWE and increased GWW, persistent after chemotherapy completion, with significant changes in group I. After third cycle, GWE and GCW were the best independent predictors for LVEF reduction; GWE decrease with>5% after third cycle predicted cardiotoxicity after chemotherapy completed (91% sensitivity, 94% specificity).

CONCLUSIONS

In NHL, myocardial work can diagnose subclinical cardiotoxicity and predict LVEF decline. These parameters should be used for sensitive evaluation of myocardial function during chemotherapy.

Application of Allometric Methods for Indexation of Left Ventricular End-Diastolic Volume to Normal Echocardiographic Data and Assessing Gender and Racial Differences

BACKGROUND

Gender and racial differences in cardiac chamber size are vital to establish normal ranges of cardiac chamber size in healthy subjects. Many studies report either nonindexed raw measurements or measurements indexed to isometric body surface area (BSA) when establishing normal reference values. Other studies advocate allometric indexation for standardization of heart size. We compared several allometric methods on gender and racial differences in left ventricular end-diastolic volume (LVEDV) measured on three-dimensional echocardiography.

METHODS

Three-dimensional echocardiographic LVEDV data from the World Alliance Societies of Echocardiography normal values study were indexed to isometric BSA, BSA^1.5, BSA^1.8, isometric height, height^2.3, height^2.9, and estimated lean body mass. Gender, racial, national, and regional differences in indexed and nonindexed LVEDV were assessed using Cohen's d statistic or Cohen's f statistic, according to the number of groups being compared. Cohen's d < 0.20 and Cohen's f < 0.10 were regarded as very small relative magnitudes of difference.

RESULTS

Differences in LVEDV among White, Black, and Asian races were smallest when BSA^1.5 or BSA^1.8 was used for indexation, followed by estimated lean body mass. LVEDV/BSA^1.5 was nearly identical for men and women (very small, d = 0.05). However, both LVEDV/BSA^1.5 and LVEDV/BSA^1.8 still provided moderate relative magnitudes of difference (f = 0.22-0.37) among geographic regions. Specifically, among Asians, Indians had the smallest LVEDV/BSA^{1.5 (1.8)}. Brazilians had the smallest LVEDV/BSA^{1.5 (1.8)} among Whites.

CONCLUSIONS

Gender and racial differences in LVEDV became smaller when LVEDV was indexed to BSA^1.5 or BSA^1.8. However, differences in LVEDV among nations remain even after applying allometric scaling. This finding suggests that differences in body composition and/or hemodynamics are potentially more important determinants of heart size than race or gender.

Normal Values of Left Ventricular Mass by Two-Dimensional and Three-Dimensional Echocardiography: Results from the World Alliance Societies of Echocardiography Normal Values Study

BACKGROUND

Although increased left ventricular (LV) mass is associated with adverse outcomes, measured values vary widely depending on the specific technique used. Moreover, the impact of sex, age, and race on LV mass remains controversial, further limiting the clinical use of this parameter. Accordingly, the authors studied LV mass using a variety of two-dimensional and three-dimensional echocardiographic techniques in a large population of normal subjects encompassing a wide range of ages.

METHODS

Transthoracic echocardiograms obtained from 1,854 healthy adult subjects (52% men) enrolled in the World Alliance Societies of Echocardiography (WASE) Normal Values Study, were divided into three age groups (young, 18-35 years; middle aged, 36-55 years; and old, >55 years). LV mass was obtained using five conventional techniques, including linear and two-dimensional methods, as well as direct three-dimensional measurement. All LV mass values were indexed to body surface area, and differences according to sex, age, and race were analyzed for each technique.

RESULTS

LV mass values differed significantly among the five techniques. Three-dimensional measurements were considerably smaller than those obtained using the other techniques and were closer to magnetic resonance imaging normal values reported in the literature. For all techniques, LV mass in men was significantly larger than in women, with and without body surface area indexing. These technique- and sex-related differences were larger than measurement variability. In women, age differences in LV mass were more pronounced and depicted significantly larger values in older age groups for all techniques, except three-dimensional echocardiography, which showed essentially no differences. LV mass was overall larger in black subjects than in white or Asian subjects.

CONCLUSIONS

Significant differences in LV mass values exist across echocardiographic techniques, which are therefore not interchangeable. Sex-, race-, and age-related differences underscore the need for separate population specific normal values.

Association of outcome with left ventricular volumes and ejection fraction measured with two- and three-dimensional echocardiography in patients referred for routine, clinically indicated studies

Objectives

We sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.

Methods

We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.

Results

LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ² = 98.3 vs. χ² = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ² = 15.9, p < 0.001 vs. χ² = 10.8, p = 0.001; 3DE LVESV: χ² = 24.4, p < 0.001 vs. χ² = 17.4, p = 0.001).

Conclusion

In patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.

Impact of correcting the 2D PISA method on the quantification of functional tricuspid regurgitation severity

AIMS

In functional tricuspid regurgitation (FTR) patients, tricuspid leaflet tethering and relatively low jet velocity could result in proximal flow geometry distortions that lead to underestimation of TR. Application of correction factors on two-dimensional (2D) proximal isovelocity surface area (PISA) equation may increase its reliability. This study sought to evaluate the impact of the corrected 2D PISA method in quantifying FTR severity.

METHODS AND RESULTS

In 102 patients with FTR, we compared both conventional and corrected 2D PISA measurements of effective regurgitant orifice area [EROA vs. corrected (EROAc)] and regurgitant volume (RegVol vs. RegVolc) with those obtained by volumetric method (VM) using three-dimensional echocardiography (3DE), as reference. Both EROAc and RegVolc were larger than EROA (0.29 ± 0.26 vs. 0.22 ± 0.21 cm2; P < 0.001) and RegVol (24.5 ± 20 vs. 18.5 ± 14.25 mL; P < 0.001), respectively. Compared with VM, both EROAc and RegVolc resulted more accurate than EROA [bias = -0.04 cm2, limits of agreement (LOA) ± 0.02 cm2 vs. bias = -0.15 cm2, LOA ± 0.31 cm2] and RegVol (bias = -3.29 mL, LOA ± 2.19 mL vs. bias = -10.9 mL, LOA ± 13.5 mL). Using EROAc and RegVolc, 37% of patients were reclassified in higher grades of FTR severity. Corrected 2D PISA method led to a higher concordance of TR severity grade with the VM method (ĸ = 0.84 vs. ĸ = 0.33 for uncorrected PISA, P < 0.001).

CONCLUSION

Compared with VM by 3DE, the conventional PISA underestimated FTR severity in about 50% of patients. Correction for TV leaflets tethering angle and lower velocity of FTR jet improved 2D PISA accuracy and reclassified more than one-third of the patients.

Left ventricular structure and function in patients with chronic kidney disease assessed by 3D echocardiography: the CPH-CKD ECHO study

Cardiovascular disease is the leading cause of mortality amongst patients with chronic kidney disease (CKD). This is the first study using 3-dimensional echocardiography (3DE) to investigate associations between adverse changes of the left ventricle, and different stages of CKD. Participants were recruited from the Copenhagen CKD cohort study and the Herlev-Gentofte CKD cohort study. Patients were stratified according to GFR category (G1 + 2: eGFR ≥ 60 mL/min/1.73 m2, G3: eGFR = 30-59 mL/min/1.73 m2, and G4 + 5: eGFR ≤ 29 mL/min/1.73 m2), and according to albuminuria (A1: UACR < 30 mg/g, A2: 30-300 mg/g, A3: > 300 mg/g). Echocardiograms were analysed for left ventricular (LV) mass index (LVMi), LV ejection fraction (LVEF), and global strain measures. In adjusted analysis, eGFR groups were adjusted for confounders and albuminuria category, while albuminuria groups were adjusted for confounders and GFR category. The study population consisted of 662 outpatients with CKD and 169 controls. Mean age was 57 ± 13 years, and 61% were males. Mean LVEF and global longitudinal strain (GLS) were increasingly impaired across eGFR groups: LVEF = 60.1%, 58.4%, and 57.8% (p = 0.013), GLS =  - 16.1%, - 14.8%, and - 14.6% (p < 0.0001) for G1 + 2, G3, and G4 + 5. LVMi and prevalence of LV hypertrophy increased with albuminuria severity: mean LVMi = 87.9 g/m2, 88.1 g/m2, and 92.1 g/m2 (p = 0.007) from A1-3. Adjusted analysis confirmed reduced LVEF in G3 compared with G1 + 2, and increased LVMi in A3 compared with A1. Increasingly impaired eGFR was associated with adverse changes in LV systolic function, while albuminuria was associated with adverse changes in LV mass assessed by 3DE. Their associations were independent of each other.

Standardization of normal values for cardiac chamber size in echocardiography

Echocardiography is used worldwide to evaluate cardiac size and function. To determine what values are abnormal, it is essential to establish normal reference values for echocardiography. The current guidelines for chamber quantification specify normative values for cardiac chambers and recommend that gender and body size be taken into account. However, these normative data were established using databases for which a variety of measurement methods were used and the majority of subjects consisted of Whites in Europe and the United States. However, several regional studies from other countries suggest that cardiac size varies globally. To overcome these limitations, the Normal Reference Ranges for Echocardiography study and the World Alliance of Societies of Echocardiography Normal Values study have recently been conducted to examine similarities and differences in cardiac chamber size and to establish normal reference values while taking worldwide diversity into account. The results from these studies have demonstrated that standardization of normal reference values for cardiac size is important. This review article aims to summarize the current status of normative echocardiographic values for cardiac chamber size.

Normal Values of Left Ventricular Size and Function on 3D Echocardiography: Results of the World Alliance of Societies of Echocardiography Study

BACKGROUND

Echocardiography remains the most widely used modality to assess left ventricular (LV) chamber size and function. Currently this assessment is most frequently performed using 2D echocardiography (2DE). Yet, 3D echocardiography (3DE) has been shown to be more accurate and reproducible than 2DE. Current normative reference values for 3D LV analysis are predominantly based on data from North America and Europe. The World Alliance of Societies of Echocardiography (WASE) study was a designed to sample normal subjects from around the world to provide more universal global reference ranges. In this study we sought to assess the world-wide feasibility of LV 3DE and report on size and function measurements.

METHODS

2262 healthy subjects were prospectively enrolled from 19 centers in 15 countries. 3D LV full-volume datasets were obtained and analyzed offline with vendor-neutral software. Measurements included end-diastolic and end-systolic volumes (EDV, ESV), ejection fraction (EF), global longitudinal and circumferential strain (GLS and GCS). Results were categorized by age (18-40, 41-65 and >65 years), sex and race.

RESULTS

1589 subjects (feasibility 70%) had adequate LV datasets for analysis. Mean normal values for indexed EDV, ESV and EF in men and women were 70 ± 15 and 65 ± 12 mL, 28 ± 7 and 25 ± 6 mL and 60 ± 5, 62 ± 5% respectively. Men had larger LV volumes and lower EF than women. GLS and GCS were higher in magnitude in women. In both sexes, LV volumes were lower and EF tended to be higher with increasing age, especially considering the differences between the youngest and oldest age groups. While GLS was similar across age groups in men, in women, the youngest and middle-age cohorts revealed higher magnitudes of GLS when compared to the oldest age group. GCS was higher in magnitude at older age in both men and women. Finally, Asians had smaller chamber sizes and higher EF and absolute strain values than both blacks and whites.

CONCLUSIONS

Age, sex, and race should be considered when defining normal reference values for LV dimension and function parameters obtained by 3DE.

Non-invasive Imaging in Coronary Syndromes - Recommendations of the European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance

Coronary artery disease (CAD) is one of the major causes of mortality and morbidity worldwide, with a high socioeconomic impact.(1) Non-invasive imaging modalities play a fundamental role in the evaluation and management of patients with known or suspected CAD. Imaging end-points have served as surrogate markers in many observational studies and randomized clinical trials that evaluated the benefits of specific therapies for CAD.(2) A number of guidelines and recommendations have been published about coronary syndromes by cardiology societies and associations, but have not focused on the excellent opportunities with cardiac imaging. The recent European Society of Cardiology (ESC) 2019 guideline on chronic coronary syndromes (CCS) and 2020 guideline on acute coronary syndromes in patients presenting with non-ST-segment elevation (NSTE-ACS) highlight the importance of non-invasive imaging in the diagnosis, treatment, and risk assessment of the disease.(3)(4) The purpose of the current recommendations is to present the significant role of non-invasive imaging in coronary syndromes in more detail. These recommendations have been developed by the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE), in collaboration with the American Society of Nuclear Cardiology, the Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance, all of which have approved the final document.

Sex differences in cardiovascular adaptations in recreational marathon runners

INTRODUCTION

There are well-established sex differences in central hemodynamic and cardiac adaptations to endurance exercise; however, controversial evidence suggests that excessive endurance exercise may be related to detrimental cardiovascular adaptations in marathoners.

PURPOSE

To examine left ventricle (LV) structure, LV function, 24-h central hemodynamics and ventricular-vascular coupling in male and female marathoners and recreationally active adults.

METHODS

52 marathoners (41 ± 5 years, n = 28 female, completed 6 ± 1 marathons/3 years) and 49 recreationally active controls (42 ± 5 years, n = 25 female) participated in the study. Three-Dimensional Echocardiography (3DE) was used to measure LV mass index and LV longitudinal (LS) circumferential (CS), area (AS), and radial strain (RS). An ambulatory blood pressure (BP) cuff was used to measure 24-h central hemodynamics (BP, pulse wave velocity, PWV, wave reflection index, RIx). Hemodynamic and 3DE measures were combined to derive the ratio of arterial elastance (Ea) to ventricular elastance (Elv) as a global measure of ventricular-vascular coupling.

RESULTS

There were no sex or group differences in LS, CS, AS, and RS (p > 0.05). Females marathoners had similar aortic BP (116 ± 9 vs. 113 ± 1 mmHg), and PWV (5.9 ± 0.5 vs. 5.9 ± 1.1 m/s) compared to female controls but lower aSBP (116 ± 9 vs. 131 ± 10 mmHg) and PWV (5.9 ± 0.5 vs. 6.2 ± 0.5 m/s) compared to male marathoners (p < 0.05). Female marathoners had lower Ea/Elv than female controls (0.67 ± 0.20 vs. 0.93 ± 0.36) and male marathoners (0.67 ± 0.20 vs. 0.85 ± 0.42, p < 0.05).

CONCLUSIONS

Women that have completed multiple marathons do not have reduced LV function or increased aortic stiffness and may have better ventricular-vascular coupling compared to male marathoners and their female untrained counterparts.

3D Echocardiography for Rheumatic Heart Disease Analysis: Ready for Prime Time

Rheumatic heart disease (RHD) remains to be a very important health issue worldwide, mainly in underdeveloped countries. It continues to be a leading cause of morbidity and mortality throughout developing countries. RHD is a delayed non-suppurative immunologically mediated inflammatory response to the throat infection caused by a hemolytic streptococcus from the A group (Streptococcus pyogenes). RHD keeps position 1 as the most common cardiovascular disease in young people aged <25 years considering all the continents. The disease can lead to valvular cardiac lesions as well as to carditis. Rheumatic fever valvular injuries lead most commonly to the fusion and thickening of the edges of the cusps and to the fusion, thickening, and shortening of the chordae and ultimately to calcification of the valves. Valvular commissures can also be deeply compromised, leading to severe stenosis. Atrial and ventricular remodeling is also common following rheumatic infection. Mixed valvular lesions are more common than isolated valvular disorders. Echocardiography is the most relevant imaging technique not only to provide diagnostic information but also to enable prognostic data. Further, it presents a very important role for the correction of complications after surgical repair of rheumatic heart valvulopathies. Three-dimensional (3D) echocardiography provides additional anatomical and morphofunctional information of utmost importance for patients presenting rheumatic valvopathies. Accordingly, three-dimensional echocardiography is ready for routine use in patients with RHD presenting with valvular abnormalities.

Higher Ventricular-Arterial Coupling Derived from Three-Dimensional Echocardiography Is Associated with a Worse Clinical Outcome in Systemic Sclerosis

Primary myocardial involvement is common in systemic sclerosis (SSc). Ventricular-arterial coupling (VAC) reflecting the interplay between ventricular performance and arterial load, is a key determinant of cardiovascular (CV) performance. We aimed to investigate VAC, VAC-derived indices, and the potential association between altered VAC and survival free from death/hospitalization for major adverse CV events (MACE) in scleroderma. Only SSc patients without any anamnestic and echocardiographic evidence of primary myocardial involvement who underwent three-dimensional echocardiography (3DE) were included in this cross-sectional study and compared with healthy matched controls. 3DE was used for noninvasive measurements of end-systolic elastance (Ees), arterial elastance (Ea), VAC (Ea/Ees) and end-diastolic elastance (Eed); the occurrence of death/hospitalization for MACE was recorded during follow-up. Sixty-five SSc patients (54 female; aged 56 ± 14 years) were included. Ees (p = 0.04), Ea (p = 0.04) and Eed (p = 0.01) were higher in patients vs. controls. Thus, VAC was similar in both groups. Ees was lower and VAC was higher in patients with diffuse cutaneous form (dcSSc) vs. patients with limited form (lcSSc) (p = 0.001 and p = 0.02, respectively). Over a median follow-up of 4 years, four patients died for heart failure and 34 were hospitalized for CV events. In patients with VAC > 0.63 the risk of MACE was higher (HR 2.5; 95% CI 1.13-5.7; p = 0.01) and survival free from death/hospitalization was lower (p = 0.005) than in those with VAC < 0.63. Our study suggests that VAC may be impaired in SSc patients without signs and symptoms of primary myocardial involvement. Moreover, VAC appears to have a prognostic role in SSc.

Validation of estimating left ventricular ejection fraction by mitral annular displacement derived from speckle-tracking echocardiography: A neglected method for evaluating left ventricular systolic function

PURPOSE

The echocardiographic measurement of left ventricular (LV) ejection fraction (EF) is dependent on professional experience and adequate visualization. Tissue motion of mitral annular displacement (TMAD) can be easily assessed using speckle-tracking echocardiography (STE), even in patients with poor acoustic windows. Therefore, this study aimed to assess whether left ventricular ejection fraction (LVEF) can be estimated using STE-derived TMAD when LVEF is not available.

METHODS

Four-hundred fifty-six outpatients were enrolled after excluding the patients whose LVEF measurements remained challenging or TMAD value could be confounded. An optimized regression model for LVEF-TMAD was developed in the derivation set (n = 287), and its reliability was verified in the validation set (n = 123) and regional wall motion abnormalities (RWMA) set (n = 46).

RESULTS

In the derivation set, the power models had the highest F-value. Therefore, the power equations were chosen to estimate LVEF by TMAD in the validation set. There was a near-zero bias and a narrow range between the observed and estimated LVEF. The highest intra-class correlation coefficient was found between the observed and the estimated LVEF by normalized TMAD at the midpoint of mitral annular (nTMADmid). Moreover, there were no significant differences between the observed and the estimated LVEF in the RWMA set.

CONCLUSION

The LVEF can be estimated with STE-derived TMAD, even for patients with RWMA, and nTMADmid may be the optimal parameter.

Development and prognostic validation of partition values to grade right ventricular dysfunction severity using 3D echocardiography

AIMS

Transthoracic 3D echocardiography (3DE) has been shown to be feasible and accurate to measure right ventricular (RV) ejection fraction (EF) when compared with cardiac magnetic resonance (CMR). However, RV EF, either measured with CMR or 3DE, has always been reported as normal (RV EF > 45%) or abnormal (RV EF ≤ 45%). We therefore sought to identify the partition values of RV EF to stratify RV dysfunction in mildly, moderately, or severely reduced as we are used to do with the left ventricle.

METHODS AND RESULTS

We used 3DE to measure RV EF in 412 consecutive patients (55 ± 18 years, 65% men) with various cardiac conditions who were followed for 3.7 ± 1.4 years to obtain the partition values which defined mild, moderate, and severe reduction of RV EF (derivation cohort). Then, the prognostic value of these partition values was tested in an independent population of 446 patients (67 ± 14 years, 58% men) (validation cohort). During follow-up, we recorded 59 cardiac deaths (14%) in the derivation cohort. Using K-Adaptive partitioning for survival data algorithm we identified four groups of patients with significantly different mortality according to RV EF: very low > 46%, 40.9% < low ≤ 46%, 32.1% < moderate ≤ 40.9%, and high ≤ 32.1%. To make the partition values easier to remember, we approximated them to 45%, 40%, and 30%. During 4.1 ± 1.2 year follow-up, 38 cardiac deaths and 88 major adverse cardiac events (MACE) (cardiac death, non-fatal myocardial infarction, ventricular fibrillation, or admission for heart failure) occurred in the validation cohort. The partition values of RV EF identified in the derivation cohort were able to stratify both the risk of cardiac death (log-rank = 100.1; P < 0.0001) and MACEs (log-rank = 117.6; P < 0.0001) in the validation cohort too.

CONCLUSION

Our study confirms the independent prognostic value of RV EF in patients with heart diseases, and identifies the partition values of RV EF to stratify the risk of cardiac death and MACE.

Left ventricular mechanical dispersion in a general population: Data from the Akershus Cardiac Examination 1950 study

AIMS

Increased left ventricular mechanical dispersion by 2D speckle tracking echocardiography predicts ventricular arrhythmias in ischaemic heart disease and heart failure. However, little is known about mechanical dispersion in the general population. We aimed to study mechanical dispersion in the general population and in diseases associated with increased risk of cardiovascular disease.

METHODS AND RESULTS

The present cross-sectional study consists of 2529 subjects born in 1950 included in the Akershus Cardiac Examination (ACE) 1950 study. Global longitudinal strain (GLS) was assessed from 17 strain segments, and mechanical dispersion calculated as the standard deviation of contraction duration of all segments. The cohort was divided according to the median value of mechanical dispersion, and multivariable linear regression models were performed with mechanical dispersion as the dependent variable. The prevalence of coronary artery disease (CAD), hypertension, obesity, and diabetes (P < 0.01 for all) was significantly higher in subjects with supra-median mechanical dispersion. In a multivariable clinical model, CAD (B = 7.05), hypertension (B = 4.15; both P < 0.001), diabetes (B = 3.39), and obesity (B = 1.89; both P < 0.05) were independently associated with increasing mechanical dispersion. When echocardiographic indices were added to the multivariable model, CAD (B = 4.38; P < 0.01) and hypertension (B = 2.86; P < 0.001) remained significant in addition to peak early diastolic tissue velocity e' (B = -2.00), GLS (B = 1.68), and ejection fraction (B = 0.22; P < 0.001 for all).

CONCLUSION

In a general middle-aged population, prevalent CAD and hypertension were associated with increasing mechanical dispersion, possibly indicating elevated risk of fatal arrhythmias and sudden cardiac death. Albeit weaker, systolic and diastolic dysfunction, were also associated with increasing mechanical dispersion.

Normal Values of Cardiac Output and Stroke Volume According to Measurement Technique, Age, Sex, and Ethnicity: Results of the World Alliance of Societies of Echocardiography Study

BACKGROUND

Assessment of cardiac output (CO) and stroke volume (SV) is essential to understand cardiac function and hemodynamics. These parameters can be examined using three echocardiographic techniques (pulsed-wave Doppler, two-dimensional [2D], and three-dimensional [3D]). Whether these methods can be used interchangeably is unclear. The influence of age, sex, and ethnicity on CO and SV has also not been examined in depth. In this report from the World Alliance of Societies of Echocardiography Normal Values Study, the authors compare CO and SV in healthy adults according to age, sex, ethnicity, and measurement techniques.

METHODS

A total of 1,450 adult subjects (53% men) free of heart, lung, and kidney disease were prospectively enrolled in 15 countries, with even distributions among age groups and sex. Subjects were divided into three age groups (young, 18-40 years; middle aged, 41-65 years; and old, >65 years) and three main racial groups (whites, blacks, and Asians). CO and SV were indexed (cardiac index [CI] and SV index [SVI], respectively) to body surface area and height and measured using three echocardiographic methods: Doppler, 2D, and 3D. Images were analyzed at two core laboratories (one each for 2D and 3D).

RESULTS

CI and SVI were significantly lower by 2D compared with both Doppler and 3D methods in both sexes. SVI was significantly lower in women than men by all three methods, while CI differed only by 2D. SVI decreased with aging by all three techniques, whereas CI declined only with 2D and 3D. CO and SV were smallest in Asians and largest in whites, and the differences persisted after normalization for body surface area.

CONCLUSIONS

The present results provide normal reference values for CO and SV, which differ by age, sex, and race. Furthermore, CI and SVI measurements by the different echocardiographic techniques are not interchangeable. All these factors need to be taken into account when evaluating cardiac function and hemodynamics in individual patients.

Normal reference values of left ventricular volumetric parameters in healthy adults-real-life single-center experience from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Background

The left ventricle (LV) is the pump of the peripheral circulation, therefore its non-invasive accurate volumetric and functional assessment is essential. Three-dimensional (3D) speckle-tracking echocardiography (STE) is a new tool with capability of quantification of LV volumes and ejection fraction (EF). In the present study, age- and gender-dependency of 3DSTE-derived LV volumetric parameters were aimed to be quantified in healthy adults.

Methods

The present study involved 298 healthy adults. Data acquisition took place over a 6 year period (2011-2017), during which 123 adults had to be excluded due to inferior image quality. The study population was further divided into 4 groups based on age decades. In every case, a complete two-dimensional echocardiography was performed followed by 3DSTE examination.

Results

No significant differences were detected between the different age groups regarding 3D end-diastolic volume (EDV) and 3D end-systolic volume (ESV) and their body surface area (BSA)-indexed counterpart. 3DEF differed significantly between the 30-39-year-old males and 40-49-year-old males (P=0.04). Between the youngest and oldest patient group, only 3D left ventricular mass (LVM) was significantly different (P=0.02). The 18-29-year-old females had a significantly different 3DLVM (P<0.001) compared to that of the 50+ year-old females. Between the 40-49-year-old and 50+ year-old females 3DLVM (P=0.02) and BSA-indexed 3DLVM (P=0.05) proved to be significantly different.

Conclusions

3DSTE seems to be a reasonably viable tool for the quantification of LV volumetric parameters.

A multicenter study of three-dimensional echocardiographic evaluation of normal pediatric left ventricular volumes and function

BACKGROUND

Three-dimensional echocardiography (3DE) evaluation of left ventricular (LV) volume and function in pediatrics compares favorably with cardiac magnetic resonance imaging. The aim of this study was to establish from a multicenter, normal pediatric z-score values of 3DE left ventricular volumes and function.

METHODS

Six hundred and ninety-eight healthy children (ages 0-18 years) were recruited from five centers. LV 3DE was acquired from the 4-chamber view. A vendor-independent software analyzed end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) using semi-automated quantification. Body surface area (BSA)-based z-scores were generated. Intraobserver and interobserver variability were calculated using intraclass correlation (ICC) and repeatability coefficient (RC).

RESULTS

Z-scores were generated for ESV, EDV, and SV. The ICC for intraobserver variability for EDV, ESV, and SV was 0.99, 0.99, and 0.99, respectively. The ICC for interobserver variability for EDV, ESV, and SV was 0.98, 0.94, and 0.98, respectively. The RC for intraobserver and interobserver variability for LV EF was 4.39% (95% CI: 3.01, 5.59) and interobserver was 7.08% (95%CI: 5.51, 8.42).

CONCLUSIONS

We report pediatric z-scores for normal LV volumes using the semi-automated method from five centers, enhancing its generalizability. 3DE evaluation of LV volumes and EF in pediatric patients is highly reproducible.

3-D Echocardiography Is Feasible and More Reproducible than 2-D Echocardiography for In-Training Echocardiographers in Follow-up of Patients with Heart Failure with Reduced Ejection Fraction

Left ventricular volumes (LVVs) and ejection fraction (LVEF) are key elements in the evaluation and follow-up of patients with heart failure with reduced ejection fraction (HFrEF). Therefore, a feasible and reproducible imaging method to be used by both experienced and in-training echocardiographers is mandatory. Our aim was to establish if, in a large echo lab, echocardiographers in-training provide feasible and more reproducible results for the evaluation of patients with HFrEF when using 3-dimensional echocardiography (3-DE) versus 2-dimensional echocardiography (2-DE). Sixty patients with HFrEF (46 males, age: 58 ± 17 y) underwent standard transthoracic 2-D acquisitions and 3-D multibeat full volumes of the left ventricle. One expert user in echocardiography (expert) and three echocardiographers with different levels of training in 2-DE (beginner, medium and advanced) measured the 2-D LVVs and LVEFs on the same consecutive images of patients with HFrEF. Afterward, the expert performed a 1-mo training in 3-DE analysis of the users, and both the expert and trainees measured the 3-D LVVs and LVEF of the same patients. Measurements provided by the expert and all trainees in echo were compared. Six patients were excluded from the study because of poor image quality. The mean end-diastolic LVV of the remaining 54 patients was 214 ± 75 mL with 2-DE and 233 ± 77 mL with 3-DE. Mean LVEF was 35 ± 10% with 2-DE and 33 ± 10% with 3-DE. Our analysis revealed that, compared with the expert user, the trainees had acceptable reproducibility for the 2-DE measurements, according to their level of expertise in 2-DE (intra-class coefficients [ICCs] ranging from 0.75 to 0.94). However, after the short training in 3-DE, they provided feasible and more reproducible measurements of the 3-D LVVs and LVEF (ICCs ranging from 0.89-0.97) than they had with 2-DE. 3-DE is a feasible, rapidly learned and more reproducible method for the assessment of LVVs and LVEF than 2-DE, regardless of the basic level of expertise in 2-DE of the trainees in echocardiography. In echo labs with a wide range of staff experience, 3-DE might be a more accurate method for the follow-up of patients with HFrEF.

Integration of three-dimensional echocardiography into the modern-day echo laboratory

Three-dimensional echocardiography (3DE) has emerged in recent decades from a conceptual, research tool to an important, useful imaging technique that can informatively impact daily clinical practice. However, its adoption into the modern-day echo laboratory requires the acknowledgment of its value, coupled with proper leadership, education, and resources to implement and integrate its use with conventional echo techniques. 3DE integration involves important updates regarding equipment and patient selection, assimilation of 3D protocols into current clinical routine, laboratory workflow adaptation, storage, and reporting. This review will provide a practical blueprint and key points of how to integrate 3DE into today's echo laboratory, necessary resources to implement 3D workflow, logistical challenges that remain, and future directions to further improve assimilation of this relevant echo technique into the laboratory.

3D echocardiography, arterial stiffness, and biomarkers in early diagnosis and prediction of CHOP-induced cardiotoxicity in non-Hodgkin's lymphoma

CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) represents standard chemotherapy in non-Hodgkin's lymphoma (NHL) with risk of cardiotoxicity. To define new parameters, such as 3D myocardial deformation, arterial stiffness, and biomarkers for early diagnosis and prediction of cardiotoxicity. 110 NHL patients with LVEF > 50%, scheduled for CHOP, were evaluated at baseline, after third cycle and chemotherapy completion. 3DE assessed LVEF and myocardial deformation: longitudinal (LS), radial, circumferential, area strain. Echo-tracking analysed arterial stiffness: PWV, β index, wave intensity. Troponin I and NT-pro-BNP were measured. After chemotherapy completion, 18 patients (16%) (group I) developed cardiotoxicity (LVEF decrease < 50%, with > 10% from baseline); 92 patients (group II) did not. Significant reduction of 3D LV deformation and increase of arterial stiffness developed starting with third cycle, with greater changes in group I. LS reduction and PWV increase after third cycle were the best independent predictors for LVEF decrease; the association of LS decrease by > 19% and PWV increase by > 27% after third cycle predicted cardiotoxicity after chemotherapy completion (90% sensitivity and 81% specificity). 3D LS and PWV can detect early chemotherapy-induced cardiotoxicity and predict LVEF decline. These parameters should be incorporated in clinical protocols to monitor cardiovascular function during chemotherapy and early intervention.

Three-dimensional echocardiographic acquisition and validity of left ventricular volumes and ejection fraction

Transthoracic (TTE) and transesophageal (TEE) three-dimensional echocardiography (3DE) is now used in daily clinical practice. Advancements in technology have improved image acquisition with higher frame rates and increased resolution. Different 3DE acquisition techniques can be used depending upon the structure of interest and if volumetric analysis is required. Measurements of left ventricular (LV) volumes are the most common use of 3DE clinically but are highly dependent upon image quality. Three-dimensional LV function analysis has been made easier with the development of automated software, which has been found to be highly reproducible. However, further research is needed to develop normal reference range values of LV function for both 3D TTE and TEE.

Relation of Mitral Annulus and Left Atrial Dysfunction to the Severity of Functional Mitral Regurgitation in Patients with Dilated Cardiomyopathy

METHODS

56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis.

RESULTS

Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p < 0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p < 0.05). MAFAC correlated inversely with EROA and Rvol (r = -0.32 and r = -0.35, p < 0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR.

CONCLUSIONS

Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

A comprehensive echocardiographic study of the right ventricular systolic function in pregnant women with inherited thrombophilia

Impact of the gestational changes on cardiac contractility is not clearly defined. Our aim was to evaluate subtle changes of the right ventricular systolic function during pregnancy, assessed by new echocardiographic techniques, in a population tested for inherited thrombophilia. 87 pregnant women, with a mean age of 32 ± 4 years, genetically tested for inherited thrombophilia (22 with high-risk inherited thrombophilia and 65 control group) were included. All participants had four echocardiographic assessments, three during pregnancy (one in each trimester) and the forth at 6 months after giving birth. The right ventricular (RV) systolic function was assessed by fractional area change, ejection fraction (EF) by 3D echocardiography, tricuspid annular velocity by tissue Doppler, tricuspid annular plane systolic excursion, and strain by speckle tracking. Pulmonary artery pressure was estimated using the pressure gradient between right atrium and RV. Parameters of RV systolic function, at visits 2-4, had lower values compared with the first visit and were significantly lower in the high-risk thrombophilia group. Tricuspid regurgitation and pressure gradient between the right atrium and the RV had a significant increase during pregnancy for all subjects. At visit 1, there were no differences between groups, but at the next three visits there were higher values of the gradient in the high-risk thrombophilia group. High-risk inherited thrombophilia impacts the RV contractility, with higher pulmonary artery pressure. Further studies are needed to assess long-term impact on RV of high-risk inherited thrombophilia.

Three-dimensional echocardiography to assess left ventricular geometry and function

Introduction: Quantification of left ventricular (LV) size and function represents the most frequent indication for an echocardiographic study. New echocardiographic techniques have been developed over the last decades in an attempt to provide a more comprehensive, accurate, and reproducible assessment of LV function.Areas covered: Although two-dimensional echocardiography (2DE) is the recommended imaging modality to evaluate the LV, three-dimensional echocardiography (3DE) has proven to be more accurate, by avoiding geometric assumptions about LV geometry, and to have incremental value for outcome prediction in comparison to conventional 2DE. LV shape (sphericity) and mass are actually measured with 3DE. Myocardial deformation analysis using 3DE can early detect subclinical LV dysfunction, before any detectable change in LV ejection fraction.Expert opinion: 3DE eliminates the errors associated with foreshortening and geometric assumptions inherent to 2DE and 3DE measurements approach very closely those obtained by CMR (the current reference modality), while maintaining the unique clinical advantage of a safe, highly cost/effective, portable imaging technique, available to the cardiologist at bedside to translate immediately the echocardiography findings into the clinical decision-making process.

Left ventricular eccentricity index measured with SPECT myocardial perfusion imaging: An additional parameter of adverse cardiac remodeling

BACKGROUND

Single-photon emission computed-tomography (SPECT) allows the quantification of LV eccentricity index (EI), a measure of cardiac remodeling. We sought to evaluate the feasibility of EI measurement with SPECT myocardial perfusion imaging and its interactions with relevant LV functional and structural parameters.

METHODS AND RESULTS

Four-hundred and fifty-six patients underwent myocardial perfusion imaging on a Cadmium-Zinc-Telluride (CZT) camera. The summed rest, stress, and difference scores were calculated. From rest images, the LV end-diastolic (EDV) and end-systolic volumes, ejection fraction (EF), and peak filling rate (PFR) were calculated. In every patient, the EI, ranging from 0 (sphere) to 1 (line), was computed using a dedicated software (QGS/QPS; Cedars-Sinai Medical Center). Three-hundred and thirty-eight/456 (74%) patients showed a normal EF (>50%), while 26% had LV systolic dysfunction. The EI was computed from CZT images with excellent reproducibility (interclass correlation coefficient: 0.99, 95% CI 0.98-0.99). More impaired EI values correlated with the presence of a more abnormal LV perfusion (P < .001), function (EF and PFR, P < .001), and structure (EDV, P < .001). On multivariate analysis, higher EDV (P < .001) and depressed EF (P = .014) values were independent predictors of abnormal EI.

CONCLUSIONS

The evaluation of LV eccentricity is feasible on gated CZT images. Abnormal EI associates with significant cardiac structural and functional abnormalities.

Three-dimensional echocardiographic comparison of left ventricular geometry and systolic function between dilated cardiomyopathy and mitral regurgitation with similar left ventricular dilation

PURPOSE

This study aimed to analyze left ventricular (LV) remodeling in patients with LV dilation using three-dimensional (3D) echocardiography, and to compare geometry and systolic function between patients with dilated cardiomyopathy (DCM) and with mitral regurgitation (MR) but similar LV dimension.

METHODS

Cross-sectional study of 60 DCM and 60 MR patients with LV end diastolic diameter (LVEDD) > 35 mm/m² , and of 60 healthy control volunteers.

RESULTS

Despite a similar LVEDD, DCM patients showed a significantly higher 3D sphericity index (3D-SI) than MR patients, whereas 3D ejection fraction (3D-EF) was significantly lower (P < .01). There was a linear relationship between 3D-EF and 3D-SI in both DCM and MR patients (r = -0. 745 and r = -0. 642, respectively; both P < .001). Receiver operating characteristic (ROC) curves showed that 3D-SI had could better discriminate between DCM and MR (sensitivity 90%; specificity 73%; AUC 0.852, P < .01) than other variables. The area under the ROC curve of 3D-SI was significantly larger than that of 3D-EF for detecting heart failure in both patients with DCM and MR.

CONCLUSIONS

LV geometry appears to be more spherical and associated with worse systolic function in DCM than in MR patients, in spite of similar LV dimensions. Systolic function correlated significantly with 3D-SI, which provided a better description of LV remodeling and could be a stronger indicator of heart failure in patients with LV dilation.

Left Ventricular Systolic Function in Pregnant Women with Inherited Thrombophilia

Objectives:The impact of the gestational changes on left ventricular contractility is not clearly defined. Our aim was to evaluate the subtle changes of left ventricular systolic function during pregnancy, assessed by new echocardiographic techniques, in a population tested for inherited thrombophilia. Material and methods:Eighty seven consecutive pregnant women, with a mean age of 32±4 years, genetically tested for inherited thrombophilia (22 with thrombophilic mutations and risk of thrombosis and 65 without significant mutations, considered as the control group) were included. All participants had four clinical and echocardiographyc visits: three during pregnancy (one in each trimester) and the forth six months after giving birth. Left ventricular (LV) systolic function was assessed from ejection fraction (EF) by 2D and 3D echocardiography, mitral annular velocities by tissue Doppler, and strain rate by 2D speckle tracking. Outcomes:There were no differences between groups for any of the echo parameters at each of the four visits. Comparing the third visit with the first one, all parameters of LV systolic function had significantly lower values at the end of pregnancy; EF decreased from 58% to 55% (2D echo), from 60% to 56% (3D TomTec), and from 58% to 55% (Auto4DLVQ), with p<0.001 for all three methods. Moreover, strain assessed by speckle traking decreased during pregnancy, with no differences between groups. In addition to this, mitral annular velocities obtained by tissue Doppler assessment decreased during the gestational period, with no differences between groups. At six months after giving birth, all values were normalized. Conclusion:During pregnancy, LV contractility has a slight decrease, with no criteria of systolic dysfunction. Thrombophilic mutations, with correct anticoagulant treatment, has no impact on LV systolic function.

Left ventricular and left atrial volume ratio assessed by three-dimensional echocardiography: Novel indices for evaluating age-related change in left heart chamber size

We hypothesized that left ventricular and left atrial volume ratio (LVLAVR) assessed by three-dimensional echocardiography (3DE) reflects age- and gender-related change in left chamber size. We aimed to (1) determine the reference values of LVLAVR, (2) investigate their age and gender dependency, and (3) clarify which anthropometric and echocardiography parameters are closely associated with these indices. Both left ventricular (LV) and left atrial (LA) volume curves were obtained using 3DE speckle tracking analytical software, and the LVLAVR curve throughout one cardiac cycle was created, from which LVLAVR at ventricular end-diastole and at ventricular end-systole were determined in 313 healthy subjects (age, 20-85 years; 51% men). The mean values of LVLAVR at ventricular end-diastole and ventricular end-systole in male subjects were 5.74 ± 1.54 and 1.37 ± 0.35, respectively. Corresponding values in female subjects were significantly lower (5.20 ± 1.47, p = .003 and 1.13 ± 0.29, p < .001) than the values in male subjects. LVLAVR at ventricular end-diastole step wisely decreased to advanced aging, and had a highest F ratio compared with other left chamber volumetric parameters in both genders. LV mass and LA ejection fraction were significantly associated with LVLAVR at ventricular end-diastole. In contrast, LV mass and LV ejection fraction were significantly coupled with LVLAVR at ventricular end-systole. This study provides the reference values for LVLAVR from a relatively large number of healthy subjects. LVLAVR may be a sensitive parameter to reflect age- and gender-related change in LV and LA volumes. Further studies should be required to determine its clinical usefulness over traditional echocardiography parameters in various cardiovascular diseases.

3-Dimensional Echocardiography: Latest Developments and Future Directions

The ongoing refinements in 3-dimensional (3D) echocardiography technology continue to expand the scope of this imaging modality in clinical cardiology by offering new features that stem from the ability to image the heart in its complete dimensionality. Over the years, countless publications have described these benefits and tested new frontiers where 3D echocardiographic imaging seemed to offer promising ways to improve patients' care. These include improved techniques for chamber quantification and novel ways to visualize cardiac valves, including 3D printing, virtual reality, and holography. The aims of this review article are to focus on the most important developments in the field in the recent years, discuss the current utility of 3D echocardiography, and highlight several interesting future directions.

Effect of Race on Echocardiographic Measures of Cardiac Structure and Function

The relations between race and cardiac structure and function are incompletely understood. We hypothesized that race-specific differences in echocardiography measurements exist. We compared the relation between echocardiography measurements and race among 12,429 nonobese adults without known cardiovascular disease who underwent echocardiography. We compared measurements between whites (n = 10,508), blacks (n = 792), Asians (n = 628), Hispanics (n = 315), Native Americans (n = 34), and multiracial/other (n = 152) cohorts. Multivariate analysis compared measurements indexed to body surface area (BSA) between races and adjusted for variables including age, gender, and mean blood pressure. Mean age was 46.9 ± 17.4 years and 60.5% were women. After multivariable adjustment and using whites as a baseline, there were significant differences (p <0.05) in left ventricular end-diastolic diameter/BSA for blacks (-0.5 mm/m²), Asians (0.4 mm/m²), Hispanics (0.2 mm/m²), and multiracial/others (0.1 mm/m²); septal wall thickness/BSA for blacks (0.4 mm/m²) and Asians (0.1 mm/m²); posterior wall thickness/BSA for blacks (0.4 mm/m²), Asians (0.1 mm/m²), Hispanics (0.04 mm/m²), and multiracial/others (0.03 mm/m²); left atrial diameter/BSA for Asians (0.2 mm/m²), Hispanics (0.3 mm/m²), and multiracial/others (0.1 mm/m²); septal and lateral e' for blacks (-0.7 cm/s; -0.9 cm/s); and peak tricuspid regurgitation gradient for blacks (4.3 mm Hg) and Asians (-0.9 mm Hg). Race is associated with significant differences in left ventricular size, left atrial size, mitral annular velocity, and tricuspid regurgitation gradient. Normal reference ranges for echocardiography measurements should utilize racially diverse cohorts to prevent misclassification of echocardiography findings based on race.

Sex-specific echocardiographic reference values: the women's point of view

: Clinical presentation, diagnosis and outcomes of cardiac diseases are influenced by the activity of sex steroid hormones. These hormonal differences explain the later development of heart diseases in women in comparison with men and the different clinical picture, management and prognosis. Echocardiography is a noninvasive and easily available technique for the analysis of cardiac structure and function. The aim of the present review is to underline the most important echocardiographic differences between sexes. Several echocardiographic studies have found differences in healthy populations between women and men. Sex-specific difference of some of these parameters, such as left ventricular (LV) linear dimensions and left atrial volume, can be explained on the grounds of smaller body size of women, but other parameters (LV volumes, stroke volume and ejection fraction, right ventricular size and systolic function) are specifically lower in women, even after adjusting for body size and age. Sex-specific differences of standard Doppler and Tissue Doppler diastolic indices remain controversial, but it is likely for aging to affect LV diastolic function more in women than in men. Global longitudinal strain appears to be higher in women during the childbearing age - a finding that also highlights a possible hormonal influence in women. All these findings have practical implications, and sex-specific reference values are necessary for the majority of echocardiographic parameters in order to distinguish normalcy from disease. Careful attention on specific cut-off points in women could avoid misinterpretation, inappropriate management and delayed treatment of cardiac diseases such as valvular disease and heart failure.