Tissue Doppler Imaging in Echocardiography: Value and Limitations

Non-invasive imaging in acute decompensated heart failure with preserved ejection fraction

Non-invasive imaging plays an increasingly important role in emergency medicine, given the trend towards smaller, portable ultrasound devices, the integration of ultrasound imaging across diverse medical disciplines, and the growing evidence supporting its clinical benefits for the patient. Heart failure with preserved ejection fraction (HFpEF) provides a compelling illustration of the impactful role that imaging plays in distinguishing diverse clinical presentations of heart failure with numerous associated comorbidities, including pulmonary, renal, or hepatic diseases. While a preserved left ventricular ejection fraction might misguide the clinician away from diagnosing cardiac disease, there are several clues provided by cardiac, vascular, and lung ultrasonography, as well as other imaging modalities, to rapidly identify (decompensated) HFpEF. Congestion remains the primary reason why patients with heart failure (irrespective of ejection fraction) seek emergency care. Furthermore, comprehensive phenotyping is becoming increasingly important, considering the development of targeted treatments for conditions exhibiting HFpEF physiology, such as cardiac amyloidosis. Timely recognition in such cases has lasting implications for long-term outcomes.

Efficacy of mitral annular velocity as an alternative marker of left ventricular global longitudinal strain to detect the risk of cancer therapy-related cardiac disorders

PURPOSE

Left ventricular longitudinal function can be rapidly evaluated by measuring S' and mitral annular plane systolic excursion (MAPSE) using tissue Doppler imaging. Even when the image quality is poor and the left ventricular endocardium is not visible, S' and MAPSE can be measured if the mitral annulus is visible. However, the utility of S' and MAPSE in diagnosing cancer therapy-related cardiac dysfunction (CTRCD) remains unclear. This study aimed to examine the diagnostic performance of S' and MAPSE and determine appropriate cutoff values.

METHODS

We retrospectively enrolled 279 breast cancer patients who underwent pre- or postoperative chemotherapy with anthracyclines and trastuzumab from April 2020 to November 2022. We compared echocardiographic data before chemotherapy, 6 months after chemotherapy initiation, and 1 year later. CTRCD was defined as a decrease in left ventricular ejection fraction below 50%, with a decrease of ≥10% from baseline or a relative decrease in left ventricular global longitudinal strain (LVGLS) of ≥15%.

RESULTS

A total of 256 participants were included in this study, with a mean age of 50.2 ± 11 years. Fifty-six individuals (22%) developed CTRCD within 1 year after starting chemotherapy. The cutoff value for septal S' was 6.85 cm/s (AUC = .81, p < .001; sensitivity 74%; specificity 73%), and for MAPSE was 11.7 mm (AUC = .65, p = .02; sensitivity 79%; specificity 45%). None of the cases with septal S' exceeding 6.85 cm/s had an LVGLS of ≤15%.

CONCLUSIONS

Septal S' is a useful indicator for diagnosing CTRCD.

HIGHLIGHTS

Septal S' decreased at the same time or earlier than the decrease in LVGLS. The septal S' demonstrated higher diagnostic ability for CTRCD compared to LVGLS.

Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography

Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario-based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance. The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.

Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy

Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.

Haemodynamic effects of hypertension and type 2 diabetes: Insights from a 4D flow MRI-based personalized cardiovascular mathematical model

Type 2 diabetes (T2D) and hypertension increase the risk of cardiovascular diseases mediated by whole-body changes to metabolism, cardiovascular structure and haemodynamics. The haemodynamic changes related to hypertension and T2D are complex and subject-specific, however, and not fully understood. We aimed to investigate the haemodynamic mechanisms in T2D and hypertension by comparing the haemodynamics between healthy controls and subjects with T2D, hypertension, or both. For all subjects, we combined 4D flow magnetic resonance imaging data, brachial blood pressure and a cardiovascular mathematical model to create a comprehensive subject-specific analysis of central haemodynamics. When comparing the subject-specific haemodynamic parameters between the four groups, the predominant haemodynamic difference is impaired left ventricular relaxation in subjects with both T2D and hypertension compared to subjects with only T2D, only hypertension and controls. The impaired relaxation indicates that, in this cohort, the long-term changes in haemodynamic load of co-existing T2D and hypertension cause diastolic dysfunction demonstrable at rest, whereas either disease on its own does not. However, through subject-specific predictions of impaired relaxation, we show that altered relaxation alone is not enough to explain the subject-specific and group-related differences; instead, a combination of parameters is affected in T2D and hypertension. These results confirm previous studies that reported more adverse effects from the combination of T2D and hypertension compared to either disease on its own. Furthermore, this shows the potential of personalized cardiovascular models in providing haemodynamic mechanistic insights and subject-specific predictions that could aid in the understanding and treatment planning of patients with T2D and hypertension. KEY POINTS: The combination of 4D flow magnetic resonance imaging data and a cardiovascular mathematical model allows for a comprehensive analysis of subject-specific haemodynamic parameters that otherwise cannot be derived non-invasively. Using this combination, we show that diastolic dysfunction in subjects with both type 2 diabetes (T2D) and hypertension is the main group-level difference between controls, subjects with T2D, subjects with hypertension, and subjects with both T2D and hypertension. These results suggest that, in this relatively healthy population, the additional load of both hypertension and T2D affects the haemodynamic function of the left ventricle, whereas each disease on its own is not enough to cause significant effects under resting conditions. Finally, using the subject-specific model, we show that the haemodynamic effects of diastolic dysfunction alone are not sufficient to explain all the observed haemodynamic differences. Instead, additional subject-specific variations in cardiac and vascular function combine to explain the complex haemodynamics of subjects affected by hypertension and/or T2D.

Strain estimation in aortic roots from 4D echocardiographic images using medial modeling and deformable registration

Even though the central role of mechanics in the cardiovascular system is widely recognized, estimating mechanical deformation and strains in-vivo remains an ongoing practical challenge. Herein, we present a semi-automated framework to estimate strains from four-dimensional (4D) echocardiographic images and apply it to the aortic roots of patients with normal trileaflet aortic valves (TAV) and congenital bicuspid aortic valves (BAV). The method is based on fully nonlinear shell-based kinematics, which divides the strains into in-plane (shear and dilatational) and out-of-plane components. The results indicate that, even for size-matched non-aneurysmal aortic roots, BAV patients experience larger regional shear strains in their aortic roots. This elevated strains might be a contributing factor to the higher risk of aneurysm development in BAV patients. The proposed framework is openly available and applicable to any tubular structures.

Left Atrial Strain Derived From Cardiac Magnetic Resonance Imaging Can Predict Outcomes of Patients With Acute Myocarditis

OBJECTIVE

There is increasing recognition that left atrial (LA) strain can be a prognostic marker of various cardiac diseases. However, its prognostic value in acute myocarditis remains unclear. Therefore, this study aimed to evaluate whether cardiovascular magnetic resonance (CMR)-derived parameters of LA strain can predict outcomes in patients with acute myocarditis.

MATERIALS AND METHODS

We retrospectively analyzed the data of 47 consecutive patients (44.2 ± 18.3 years; 29 males) with acute myocarditis who underwent CMR in 13.5 ± 9.7 days (range, 0-31 days) of symptom onset. Various parameters, including feature-tracked CMR-derived LA strain, were measured using CMR. The composite endpoints included cardiac death, heart transplantation, implantable cardioverter-defibrillator or pacemaker implantation, rehospitalization following a cardiac event, atrial fibrillation, or embolic stroke. The Cox regression analysis was performed to identify associations between the variables derived from CMR and the composite endpoints.

RESULTS

After a median follow-up of 37 months, 20 of the 47 (42.6%) patients experienced the composite events. In the multivariable Cox regression analysis, LA reservoir and conduit strains were independent predictors of the composite endpoints, with an adjusted hazard ratio per 1% increase of 0.90 (95% confidence interval [CI], 0.84-0.96; P = 0.002) and 0.91 (95% CI, 0.84-0.98; P = 0.013), respectively.

CONCLUSION

LA reservoir and conduit strains derived from CMR are independent predictors of adverse clinical outcomes in patients with acute myocarditis.

Effect of resistance exercise on cardiac perturbations and systolic performance: A cross-over randomized trial comparing volumes and techniques

This study investigated the magnitude and time-course of resistance exercise (RE) technique induced transient cardiac perturbations. Twenty-four participants were assigned to one of four arms: sets to failure or non-failure with 8-10 repetition maximum (RM), and sets to failure or non-failure with 15RM. Echocardiographic and blood pressure (BP) data were recorded at baseline and 30 min, 6 h and 24 h post-exercise. In all groups end-systolic circumferential wall stress (cESS), and ratio of transmitral inflow velocities (E/A) were significantly decreased while posterior wall thickness (PWT), global circumferential strain (GCS), GCS strain rate (GCSR), global longitudinal strain rate (GLSR), and stroke volume (SV) were significantly increased for up to 6 h of follow-up. In the 15RM groups, left ventricular (LV) mass and interventricular septal thickness (IVST) were significantly increased, and left atrial (LA) area was significantly decreased (p < 0.05) compared to the 8-10 RM groups. In the 15RM groups, RE decreased global longitudinal strain (GLS) and increased ejection fraction (EF) (p<0.01). After RE, transient cardiac perturbations, the reduction in LA compliance, and the improvement in LV myofibril geometry were volume dependent and influenced more by sets to failure technique. RE increased GCS and reduced the afterload, thus helping to preserve SV and EF.

Automated multi-beat tissue Doppler echocardiography analysis using deep neural networks

Tissue Doppler imaging is an essential echocardiographic technique for the non-invasive assessment of myocardial blood velocity. Image acquisition and interpretation are performed by trained operators who visually localise landmarks representing Doppler peak velocities. Current clinical guidelines recommend averaging measurements over several heartbeats. However, this manual process is both time-consuming and disruptive to workflow. An automated system for accurate beat isolation and landmark identification would be highly desirable. A dataset of tissue Doppler images was annotated by three cardiologist experts, providing a gold standard and allowing for observer variability comparisons. Deep neural networks were trained for fully automated predictions on multiple heartbeats and tested on tissue Doppler strips of arbitrary length. Automated measurements of peak Doppler velocities show good Bland-Altman agreement (average standard deviation of 0.40 cm/s) with consensus expert values; less than the inter-observer variability (0.65 cm/s). Performance is akin to individual experts (standard deviation of 0.40 to 0.75 cm/s). Our approach allows for > 26 times as many heartbeats to be analysed, compared to a manual approach. The proposed automated models can accurately and reliably make measurements on tissue Doppler images spanning several heartbeats, with performance indistinguishable from that of human experts, but with significantly shorter processing time. HIGHLIGHTS: • Novel approach successfully identifies heartbeats from Tissue Doppler Images • Accurately measures peak velocities on several heartbeats • Framework is fast and can make predictions on arbitrary length images • Patient dataset and models made public for future benchmark studies.

Functional outcomes in post Covid-19 patients with persistent dyspnea: multidisciplinary approach

BACKGROUND

Post-acute sequelae of SARS-CoV-2 (PASC) have emerged as a major health issue in patients who have previously been infected with Covid-19 virus.

PURPOSE

we aimed at the assessment of functional outcomes in post Covid-19 patients with persistent dyspnea using a multidisciplinary approach including clinical assessment, laboratory investigations, exercise ECG, and different echo-Doppler modalities, including left atrial functions.

METHODS

The current observational randomized controlled study conducted on 60- patients one month after recovery from Covid-19 infection presented with persistent dyspnea compared to 30 healthy volunteers. All participants were subjected to evaluation of dyspnea by different scores, laboratory investigations, stress ECG, and echo-Doppler examination to measure LV dimensions, volumes, systolic and diastolic functions by M-mode, 2D, and tissue Doppler imaging in addition to 2-D speckle tacking LA strain.

RESULTS

Post Covid-19 patients had persistent elevation of inflammatory markers, low functional capacity (evidenced by a higher NYHA class, m MRC score, PCFS scale) and decreased METs by stress ECG compared to control group. Post Covid-19 patients showed LV diastolic dysfunction and impairment of 2D-STE LA functions compared to control group. We found negative correlations between LA strain with NYHA class, mMRC scale, LAVI, ESR and CRP; meanwhile, there were significant positive correlations between LA strain with exercise duration and METs.

CONCLUSION

post Covid patients presented with persistent dyspnea demonstrated low functional capacity evidenced by different scores and stress ECG. Moreover, patients with post Covid syndrome showed elevated inflammatory biomarkers, LV diastolic dysfunction in addition to impaired LA strain functions. Impairment of LA strain was closely correlated to different functional scores, inflammatory biomarkers, exercise duration, and METs suggesting that these could to be the possible etiologies for the persistence of post Covid symptoms.

Associations among preoperative transthoracic echocardiography variables and cerebral near-infrared spectroscopy values at baseline before anesthesia in patients undergoing cardiac surgery: a retrospective observational study

Cerebral tissue oximetry with near-infrared spectroscopy (NIRS) is used to monitor cerebral oxygenation during cardiac surgery. To date, reduced baseline cerebral NIRS values have been attributed to reduced cerebral blood flow primarily based on a significant positive correlation between left ventricular ejection fraction (LVEF) and baseline rSO₂ measured with the INVOS 5100C oximeter. Reportedly, however, rSO₂, but not StO₂ measured with the FORESIGHT Elite oximeter, correlated with LVEF. We, thus, investigated associations among baseline NIRS values measured with three different oximeters before anesthesia for cardiac surgery and preoperative transthoracic echocardiography (TTE) variables, including LVEF, to examine whether there are inter-device differences in associations among baseline NIRS values and TTE variables. Using Spearman's correlation coefficient, we retrospectively investigated associations among 15 preoperative TTE variables, including LVEF, and baseline NIRS values, including rSO₂, StO₂, and TOI with the NIRO-200NX oximeter in 1346, 515, and 301 patients, respectively. Only rSO₂ (p < 0.00001), but not TOI or StO₂ (p > 0.05), positively correlated with LVEF. On the other hand, baseline rSO₂, TOI, and StO₂ consistently, negatively correlated with the left atrial diameter index (LADI), early diastolic transmitral flow velocity (E), E-to-early diastolic mitral annular velocity ratio (E/e'), estimated right ventricular systolic pressure (eRVP), and inferior vena cava diameter index (IVCDI) (p < 0.0005 to p < 0.00001). Because all of these five TTE variables could be positively associated with right as well as left ventricular filling pressure, our results indicated that reduced baseline NIRS values were consistently associated not with reduced LVEF but with TTE findings indicative of elevated biventricular filling pressure. Our data suggest that regional venous congestion greatly contributes to reduced baseline NIRS values in patients undergoing cardiac surgery.

Left atrial appendage thrombus formation, potential of resolution and association with prognosis in a large real-world cohort

Comprehensive data on factors influencing left atrial appendage (LAA) thrombus formation, resolution and impact on survival are limited. In this single-center, retrospective study 7759 (2010-2015) patients with symptomatic ongoing atrial fibrillation (AF) on admission were screened for LAA thrombi. 450 patients had LAA thrombi. 481 patients without LAA thrombi were randomly selected as controls. We assessed clinical, echocardiographic, laboratory parameters and long-term survival of both groups. Patients with LAA thrombi compared to controls were older, had more strokes, higher CHA₂DS₂ -VASc scores, worse renal function, less controlled diabetes, advanced heart failure, lower LAA emptying velocities, higher levels of cardiac and inflammatory markers (all p < 0.001). 56.3% of followed-up patients (304) dissolved their LAA thrombi. Chances of thrombus resolution increased with rising LAA flow velocities (OR 1.061, p = 0.022), whereas advanced age (OR 0.950, p < 0.001) and presence of permanent AF (OR 0.354, p < 0.001) decreased chances of thrombus resolution. Presence of LAA thrombi was associated with a markedly reduced 10-year survival probability (31% versus 69%). LAA thrombus formation is promoted by advanced structural heart disease, inflammation, diabetes and impaired renal function. Younger age, non-permanent AF and higher LAA flow velocities were predictors of thrombus resolution. Thrombus formation was associated with poor prognosis.

Computational Analysis of Cardiac Contractile Function

PURPOSE OF REVIEW

Heart failure results in the high incidence and mortality all over the world. Mechanical properties of myocardium are critical determinants of cardiac function, with regional variations in myocardial contractility demonstrated within infarcted ventricles. Quantitative assessment of cardiac contractile function is therefore critical to identify myocardial infarction for the early diagnosis and therapeutic intervention.

RECENT FINDINGS

Current advancement of cardiac functional assessments is in pace with the development of imaging techniques. The methods tailored to advanced imaging have been widely used in cardiac magnetic resonance, echocardiography, and optical microscopy. In this review, we introduce fundamental concepts and applications of representative methods for each imaging modality used in both fundamental research and clinical investigations. All these methods have been designed or developed to quantify time-dependent 2-dimensional (2D) or 3D cardiac mechanics, holding great potential to unravel global or regional myocardial deformation and contractile function from end-systole to end-diastole. Computational methods to assess cardiac contractile function provide a quantitative insight into the analysis of myocardial mechanics during cardiac development, injury, and remodeling.

Tissue Doppler echocardiography and outcome in arrhythmogenic right ventricular cardiomyopathy

AIMS

This study aimed at investigating whether tissue Doppler imaging (TDI) is associated with adverse events in arrhythmogenic right ventricular cardiomyopathy (ARVC).

METHODS AND RESULTS

Transthoracic echocardiography was performed in 72 patients with definite (n = 63) or borderline (n = 9) ARVC diagnosed according to the 2010 Task Force Criteria and included in the prospective Zurich ARVC registry. Myocardial peak systolic tissue velocity (S') was measured by TDI at lateral tricuspid (tricuspid S'), medial mitral (septal S'), and lateral mitral annulus (lateral S'). Association of echocardiographic parameters with outcome was assessed by univariable Cox regression. During a median follow-up of 4.9 ± 2.6 years, 6 (8.3%) patients died of cardiovascular cause or received heart transplantation and 21 (29.2%) patients developed sustained ventricular arrhythmia. Tricuspid, septal, and lateral S' were lower in patients who died (p = 0.001; p < 0.001; p = 0.008; respectively), while tricuspid and septal S' were lower in those with ventricular arrhythmia (p = 0.001; p = 0.008; respectively). There was a significant association of tricuspid, septal, and lateral S' with mortality (HR = 1.61, p = 0.011; HR = 2.15, p = 0.007; HR = 1.67, p = 0.017; respectively), while tricuspid and septal S' were associated with ventricular arrhythmia (HR = 1.20, p = 0.022; HR = 1.37, p = 0.004; respectively). Kaplan-Meier analyses demonstrated a higher freedom from mortality with tricuspid S' >8 cm/s (p = 0.001) and from ventricular arrhythmia with S' >10.5 cm/s (p = 0.021).

CONCLUSIONS

This study demonstrates that TDI provides information on the ARVC phenotype, is associated with adverse events in ARVC patients, and differentiates between patients with and without adverse events.

Right Ventricular Function in Neonates During Early Postnatal Period: A Prospective Observational Study

Previous echocardiographic studies were mainly focused on preterm infants and early fetal-to-neonatal transition period, whereas little is known about changes in the parameters of the right ventricular (RV) function after 72 h of life. Our aim was to quantitatively characterize potential changes in RV function by echocardiography in healthy term newborns between the third and the seventh day of life. We conducted a prospective observational study in 35 full-term newborns, in whom we performed echocardiographic examinations on the third and the seventh day of life. We assessed RV function, output and afterload and found a significant increase in all tissue Doppler velocities as well as in RV longitudinal strain, a higher mean RV outflow tract velocity time integral and lower myocardial performance index (MPI'), whereas the tricuspid annular plane systolic excursion, RV filling pattern, and RV outflow tract acceleration time were not significantly different between the third and the seventh day of life. Conclusions: Increased RV systolic and diastolic myocardial velocities, cardiac output and longitudinal deformation and decreased RV MPI' between the third and the seventh day of life point to a reduction of RV afterload and adaptive myocardial maturation in term newborns during this period. Moreover, PW-TDI and 2D speckle-tracking echocardiography seem to be more sensitive for evaluating RV function in comparison with M-mode echocardiography and pulsed-wave Doppler analysis of RV filling.

Investigating the Relationship Between Cardiac Function and Insulin Sensitivity in Horses: A Pilot Study

Metabolic syndrome in humans is commonly associated with cardiovascular dysfunction, including atrial fibrillation and left ventricular diastolic dysfunction. Although many differences exist between human and equine metabolic syndrome, both of these conditions share some degree of insulin resistance. The aims of this pilot study were to investigate the relationship between insulin sensitivity and cardiac function. Seven horses (five mares, two geldings, aged 17.2 ± 4.2 years, weight 524 ± 73 kg) underwent insulin-modified frequently sampled intravenous glucose tolerance testing to determine insulin sensitivity (mean 2.21 ± 0.03 × 10−4 L/min/mU). Standard echocardiograms were performed on each horse, including two-dimensional, M-mode, and pulse-wave tissue Doppler imaging. Pearson and Spearman correlation analyses were used to determine the association of insulin sensitivity with echocardiographic measures of cardiac function in 5 horses. Insulin sensitivity was found to be significantly correlated with peak myocardial velocity during late diastole (r = 0.89, P = 0.0419), ratio between peak myocardial velocity in early and late diastole (r = −0.92, P = 0.0263), isovolumetric relaxation time (r = −0.97, P = 0.0072), and isovolumetric contraction time (ρ = −0.90, P = 0.0374). These preliminary data suggest that decreased insulin sensitivity is correlated with alterations in both systolic and diastolic function, as measured with tissue Doppler imaging (TDI). Due to the small sample size of this study, the relationship between insulin sensitivity and myocardial function in horses requires further investigation.

Feasibility of tissue-tracking mitral annular displacement in single four-chamber view as a simple index of left ventricular longitudinal deformation

BACKGROUND

Left ventricular global longitudinal strain (LVGLS) has prognostic value for adverse cardiac events. Application of speckle-tracking technology to mitral annulus provides easy assessment of tissue-tracking mitral annular displacement (TMAD) in apical four-chamber view. The study aimed to examine whether TMAD can be used as a simple index of LV longitudinal deformation in patients with and without preserved ejection fraction (EF).

METHODS

The study population consisted of 95 consecutive subjects. GLS was assessed from three apical views. TMAD was evaluated as the base-to-apex displacement of septal (TMADsep), lateral (TMADlat), and mid-point of annular line (TMADmid) in apical 4-chamber view. The percentage of TMADmid to LV length from the mid-point of mitral annuls to the apex at end-diastole (%TMADmid) was calculated. We compared each TMAD parameter with GLS by linear regression analysis, and analyzed each TMAD parameter by receiver operating characteristic (ROC) curve to detect impaired LV longitudinal deformation (|GLS|< 15.0%).

RESULTS

There were good correlations between each TMAD parameter and GLS (TMADsep: r² = 0.59, p < 0.01. TMADlat: r² = 0.65, p < 0.01. TMADmid: r² = 0.68, p < 0.01. %TMADmid: r² = 0.75, p < 0.01). According to ROC curve, %TMADmid < 10.5% was the best cut-off value in determining impaired LV longitudinal deformation (|GLS|≤ 15.0%) with a sensitivity of 95% and a specificity of 93%. The area under the curve (AUC) of %TMADmid was 0.98 (95% confidence intervals (CI) 0.93-0.99).

CONCLUSIONS

TMAD using speckle-tracking echocardiography quickly estimated from single apical four-chamber view can be used as a simple index for detection of impaired LV longitudinal deformation in patients with and without preserved EF.

Diagnostic Value and Clinical Performance of Cardiac Ultrasound in Patients with Chronic Heart Failure with Hypertension

Objective

To assess the diagnostic value and clinical performance of cardiac ultrasound in patients with chronic heart failure and hypertension.

Methods

In this prospective study, between August 2017 and January 2020, 50 patients with chronic heart failure and hypertension were recruited and assigned to the study group and 50 healthy individuals during the same period after physical examinations were included in the control group. Cardiac ultrasound examinations were performed on the participants, and the results were compared and analyzed.

Results

The study group had a higher left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular ejection fraction (LVEF), and late diastolic peak flow velocity (A wave) and showed lower early diastolic peak flow velocity (E wave) and late diastolic peak flow velocity/lower early diastolic peak flow velocity (E/A) ratio levels than in the control group. The study group had 15 patients with grade I cardiac function (ultrasound detection rate of 100%), 18 patients with grade II cardiac function (ultrasound detection rate of 100%), and 17 patients with grade III cardiac function (ultrasound detection rate of 100%). Grade I cardiac function patients showed the lowest LVEDD, LVESD, and E/A and the highest LVEF than grade II patients, followed by grade III patients. The study group showed higher LVEF and echocardiographic estimation of the pulmonary arterial systolic pressure (PASP) and lower right ventricular lateral wall systolic excursion velocity and tricuspid annular plane systolic excursion (TAPSE) than the control group. Chronic heart failure with hypertension was associated with high levels of right atrial total emptying volume (RAVIt), right atrial passive emptying volume (RAVIp), right atrial active emptying volume (RAVIa), and right atrial active emptying fraction (RAVIaEF) and low levels of right atrial total emptying fraction (RAVItEF) and right atrial passive emptying fraction (RAVIpEF) versus the healthy status (all P < 0.05).

Conclusion

Cardiac ultrasound is a noninvasive operation with low cost, high repeatability, and accurate detection, which can identify right heart function impairment at an early stage, assist clinical treatment, and improve patient prognosis, so it is worthy of promotion and application.

Spectral Analysis of Tissue Displacement for Cardiac Activation Mapping: Ex Vivo Working Heart and In Vivo Study

Characterizing myocardial activation is of major interest for understanding the underlying mechanism of cardiac arrhythmias. Electromechanical wave imaging (EWI) is an ultrafast ultrasound-based method used to map the propagation of the local contraction triggered by electrical activation of the heart. This study introduces a novel way to characterize cardiac activation based on the time evolution of the instantaneous frequency content of the cardiac tissue displacement curves. The first validation of this method was performed on an ex vivo dataset of 36 acquisitions acquired from two working heart models in paced rhythms. It was shown that the activation mapping described by spectral analysis of interframe displacement is similar to the standard EWI method based on zero-crossing of interframe strain. An average median error of 3.3 ms was found in the ex vivo dataset between the activation maps obtained with the two methods. The feasibility of mapping cardiac activation by EWI was then investigated on two open-chest pigs during sinus and paced rhythms in a pilot trial of cardiac mapping with an intracardiac probe. Seventy-five acquisitions were performed with reasonable stability and analyzed with the novel algorithm to map cardiac contraction propagation in the left ventricle (LV). Sixty-one qualitatively continuous isochrones were successfully computed based on this method. The region of contraction onset was coherently described while pacing in the imaging plane. These findings highlight the potential of implementing EWI acquisition on intracardiac probes and emphasize the benefit of performing short time-frequency analysis of displacement data to characterize cardiac activation in vivo.

Tissue Doppler echocardiography in children with OSA before and after tonsillectomy and adenoidectomy: A systematic review and meta-analysis

BACKGROUND

When to order an echocardiogram in children with obstructive sleep apnea (OSA) is debated. Studies evaluating the utility of pre-operative standard echocardiography are inconsistent. Tissue Doppler imaging (TDI) is an additional technique that quantifies the velocity of myocardial motion to assess cardiac function. The utility of TDI in pediatric OSA remains unclear.

METHODS

A systematic review and meta-analysis were performed in accordance with PRISMA guidelines using PubMed, Scopus, CINAHL, and Cochrane Library databases. Studies of echocardiographic findings using TDI in children with polysomnogram confirmed OSA before and after tonsillectomy and adenoidectomy (T&A) were included. 1,423 studies were screened, and 4 studies met inclusion criteria. Meta-analysis of echocardiographic findings was performed.

RESULTS

Data from 560 children were analyzed. Study groups included pre- and post-T&A children with OSA and non OSA controls. Pre-T&A S' wave at the tricuspid annulus (S' RV) was decreased with a mean difference of -1.04 [95% CI -1.57, -0.52, p < 0.001] and E'/A' ratio at the mitral annulus (E'/A' LV) was decreased with a mean difference of -0.74 [95% CI -0.85, -0.64, p < 0.001] when compared to controls. These variables were not statistically different when comparing post-T&A to controls.

CONCLUSIONS

TDI appears to successfully detect subclinical changes in cardiac function in children with OSA. However, echocardiography parameters of post-T&A and non OSA control children were similar. Further prospective studies stratified by OSA severity are needed with both TDI and standard echocardiography to define the utility of pre-operative cardiac imaging.

Evaluation of Changes in the Cardiac Function before and after Transcatheter Edge-to-Edge Mitral Valve Repair in Healthy Dogs: Conventional and Novel Echocardiography

Mitral valve regurgitation is a common canine heart disease. Transcatheter Edge-to-Edge Repair (TEER) is a transcatheter, edge-to-edge mitral repair device that uses a hybrid approach. No detailed information has been published on the hemodynamic effect of TEER on cardiac function. The aim of this report is to provide a longitudinal observation of the cardiac functional changes observed after TEER implantation in normal dogs using traditional, two-dimensional speckle tracking, and color M-mode echocardiographic methods. In the current report, TEER was implanted into two healthy dogs under general anesthesia. An echocardiographic examination was performed at baseline and weekly postoperative follow-ups were conducted until the fourth week. Successful TEER implantation was achieved with a short operation time (98 and 63 min) in the two dogs. Functional mitral valve regurgitation, elevated E/e' ratio, elevated radial strain, and stable intraventricular pressure gradients (IVPG) were observed after the operation in the dogs. Mild non progressive mitral valve stenosis was observed in both dogs. TEER is a minimally invasive method for mitral valve surgery that necessitates more clinical trials. With longitudinal observation of heart function using novel approaches, better outcomes will be expected.

Long-term consequences of previous preeclampsia and complicated pregnancy: analysis of echocardiographic aspects

AIM

To evaluated echocardiographic aspects in women with history of preeclampsia or preeclampsia-related complications in their previous pregnancies.

MATERIALS AND METHODS

Consecutive women receiving echocardiography during daily clinical echolab activity were studied using complete echocardiographic examination data and anamnestic data collection of hypertension, diabetes, dyslipidemia, and rheumatic diseases. Studied women should have at least one pregnancy in more than the 10 past years, and were subdivided into two groups according to the history of complicated or physiological pregnancy. Complicated pregnancies were defined by preeclampsia or preeclampsia-related complication, such as preterm delivery or small-for-gestational age newborn. Echocardiographic parameters and prevalence of hypertension, diabetes, dyslipidemia, and rheumatic disease were compared between the two groups of studied women.

RESULTS

From March 2016 to May 2020, 545 women were studied, of whom 218 had a history of complicated pregnancy (mean age 60.81 ± 11.109 years vs. 62.78 ± 9.758 years of not complicated pregnancy; P = 0.03). Compared with physiological pregnancy women, complicated pregnancy ones were shorter (159.97 ± 6.608 vs. 161.42 ± 6.427 cm; P = 0.012) with lower body surface area (1.678 ± 0.1937 vs. 1.715 ± 0.1662 m2; P = 0.02), had higher prevalence of diabetes (6.9 vs. 3.1%; P = 0.04; odds ratio = 2.34; CI 1.0323--5.3148) and rheumatic diseases (33 vs. 22.3%; P = 0.006; odds ratio = 1.72; CI 1.1688--2.5191), and showed a slight, not significant higher prevalence of hypertension. As for echocardiographic parameters, they showed significantly higher values of end-diastolic left ventricular posterior wall (LPWd) (P = 0.034), a trend toward a more concentric geometry, and a worse longitudinal systolic left and right ventricle performance, represented by lower tissue Doppler systolic waves (septal: 7.41 ± 1.255 vs. 7.69 ± 1.376 cm/s; P = 0.018; and tricuspidalic: 12.64 ± 2.377 vs. 13.32 ± 2.548 cm/s; P = 0.003).

CONCLUSION

Patients with previous preeclampsia present an increased risk of hypertension, diabetes, and rheumatic diseases, suggesting that these women could share a specific predisposition to a high-risk profile. Furthermore, they show a higher prevalence of classically considered echocardiographic hypertensive-derived cardiac damage, suggesting structural and functional left ventricular modifications as subclinical aspects of long-term worse cardiovascular prognosis for these women.

Neutrophil degranulation biomarkers characterize restrictive echocardiographic pattern with diastolic dysfunction in patients with diabetes

OBJECTIVE

To investigate the potential association between neutrophil degranulation and patterns of myocardial dysfunction in a cohort of patients with type 2 diabetes mellitus (T2DM).

BACKGROUND

Two distinct phenotypes of diabetic cardiomyopathy have been described: a restrictive phenotype with diastolic dysfunction (restrictive/DD) and a dilative phenotype with systolic dysfunction (dilative/SD). However, the underlying determinants of these two patterns are not yet recognized.

METHODS

In this single-centre, observational, cross-sectional study, 492 patients were recruited. Ultrasonographic measurements were performed by two experienced sonographers, blinded to the clinical data of the participants. Serum biomarkers of neutrophil degranulation were measured by enzyme-linked immunosorbent sandwich assay (ELISA).

RESULTS

After adjustment for confounders, resistin, myeloperoxidase, matrix metalloproteinase 8 and matrix metalloproteinase 9/tissue inhibitor of metalloproteinases 1 complex were positively associated with the restrictive/DD pattern compared with the normal pattern. Similarly, MPO was positively associated with the dilative/SD pattern compared with the normal pattern, and resistin was negatively associated with the dilative/SD pattern compared with the restrictive/DD pattern.

CONCLUSIONS

Neutrophil degranulation is associated with the restrictive/DD echocardiographic pattern in patients with T2DM, but not with the normal pattern and dilative/SD patterns. Neutrophils could have a pivotal role in the pathogenesis of myocardial dysfunction, and particularly diastolic dysfunction, in patients with T2DM.

Assessment of cardiac function in syncopal children without organic causes

BACKGROUND

Syncope is a common problem in children and adolescents. However, a large proportion of syncope cases have no underlying cause.

PURPOSE

This study aimed to identify the factors affecting the severity of syncope using tissue Doppler imaging (TDI).

METHODS

This retrospective study included 61 children and adolescents with syncope who underwent echocardiography. The head-up-tilt test (HUT) was performed when there was a more severe syncopal event. We compared the echocardiographic findings between the execute HUT and nonexecute HUT, negative HUT result and positive HUT result, and normal electrocardiogram (ECG) and abnormal ECG groups. Data were analyzed using an unpaired t test post hoc analysis.

RESULTS

In the execute and nonexecute HUT groups, the odds ratios were 0.55 for medial E/E' (P=0.040) and 0.64 for lateral E/E' (P=0.049). Comparison of the results of the decreased, normal, and increased groups for lateral E/E' revealed a significant difference in the execution HUT and nonexecute HUT groups (overall, P=0.004; decreased vs. increased, P= 0.003; normal vs. increased, P=0.050).

CONCLUSION

Medial E/E' and lateral E/E' were decreased in patients with severe syncopal events. These findings suggest that the presence of left ventricular diastolic deterioration may cause hypoperfusion even in the absence of organic causes and, consequently, increase syncope severity and frequency. The TDI measured by echocardiography can be used as an index to predict syncope recurrence and/or severity.

Left Atrial Function Predicts Outcome in Dilated Cardiomyopathy: Fast Long-Axis Strain Analysis Derived from MRI

Background There is increasing recognition that left atrial (LA) function is prognostically important in cardiovascular disease. LA strain is a sensitive parameter to describe complex LA phasic function. However, the prognostic value of LA strain in participants with idiopathic dilated cardiomyopathy (DCM) remains unclear. Purpose To evaluate the prognostic value of LA strain derived from cardiac MRI in study participants with idiopathic DCM. Materials and Methods Participants with idiopathic DCM who underwent cardiac MRI between June 2012 and November 2018 were prospectively enrolled. The fast long-axis strain MRI method was performed to assess LA strain. The primary end point was all-cause mortality and heart transplant, and the secondary end point was a combination of primary end point, heart failure readmission, and aborted sudden cardiac death. Cox regression analyses and Kaplan-Meier survival analysis were performed to identify the association between variables and outcomes. Results There were 497 participants (mean age, 47 years ± 14 [standard deviation]; 357 men) evaluated. During a median follow-up of 36 months (interquartile range, 26-54 months), 113 participants reached primary end points and 203 participants reached secondary end points. LA reservoir, conduit and booster strain, and strain rate were lower in participants with primary end points (P < .001). In multivariable Cox regression analysis, LA reservoir strain and conduit strain were independent predictors for primary end point (hazard ratio [HR] per 1% increase, 0.95 [95% CI: 0.91, 0.99; P = .008] and 0.92 [95% CI: 0.87, 0.98; P = .010], respectively) and secondary end points (HR per 1% increase, 0.95 [95% CI: 0.93, 0.97; P < .001] and 0.93 [95% CI: 0.89, 0.97; P < .001], respectively). In addition, LA reservoir strain and conduit strain added incremental prognostic value to clinical risk factors and late gadolinium enhancement presence (all, P < .05). Conclusion Left atrial reservoir and conduit strain, derived from cardiac MRI by using the fast long-axis method, were independent predictors of adverse clinical outcomes in idiopathic dilated cardiomyopathy. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Ambale-Venkatesh in this issue.

Values of left ventricular diastolic function assessed by left atrial volumes and Doppler echocardiography in healthy Angolans: Effect of age and gender: A pilot study

INTRODUCTION

Studies about the reference values of conventional and tissue Doppler echocardiography in African populations are limited.

OBJECTIVES

To evaluate the effect of aging and gender in left ventricular diastolic function assessed by conventional and tissue Doppler echocardiography in healthy Angolans.

METHODS

Cross-sectional study involving healthy adult participants attending a diagnostic center in Luanda, Angola. Two-dimensional transthoracic B-mode and Doppler echocardiography were performed according to the Guidelines of the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

RESULTS

A total of 103 men (47.5%) (mean age: 39.5 ± 10.8) and 114 women (52.5%) (mean age: 43.0 ± 12.5 years) were included. Women were older (p = 0.025) and showed smaller body surface area (p < 0.001) than men. Mitral E velocity and E/e' ratio were higher in women than in men. While DT of mitral E velocity was longer in men than in women (p = 0.041), E velocity, E/A ratio, and average e' velocity showed a negative significant correlation with increasing age (r - 0.33; p ≤ 0.001; r - 0.48; p ≤ 0.001 and r - 0.41; p ≤ 0.0001, respectively). Conversely, A wave velocity showed a significant positive correlation with age (r 0.47; p < 0.001).

CONCLUSIONS

In a healthy Angolan adult population, the variables of left ventricular diastolic function declined with age, reflecting a normal aging process. This must be taken into account when assessing diastolic function at different age categories.

Left Ventricular Strain Rate for Intraoperative Evaluation of Cardiac Diastolic Function by Transesophageal Echocardiography: The Correlation Between Late Diastolic Peak Longitudinal Strain Rate and the Severity of Diastolic Dysfunction

OBJECTIVES

Speckle-tracking echocardiography is a promising tool for evaluating cardiac diastolic dysfunction. A correlation between left atrial strain rate during atrial contraction and the severity of diastolic dysfunction previously has been demonstrated. Because visualization of the left atrial walls is difficult with transesophageal echocardiography, the authors evaluated the use of left ventricular strain rate during atrial contraction as a substitute for left atrial strain rate to intraoperatively measure the extent of cardiac diastolic dysfunction.

DESIGN

Retrospective clinical study.

SETTING

Single institutional study.

PARTICIPANTS

Sixty-six patients who underwent cardiac surgery between January 2018 and January 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Preoperative echocardiographic reports and intraoperative echocardiographic images of the participants were studied. The correlation of cardiac diastolic dysfunction stage with the peak longitudinal strain rate during late diastole and the time to peak value were evaluated. The late diastolic peak longitudinal strain rate was correlated significantly with the stage of diastolic dysfunction (r = -0.64, p < 0.0001). There was no significant correlation between the stage of diastolic dysfunction and the time to peak value (r = -0.17, p = 0.18). A late diastolic peak longitudinal strain rate <0.68 1/s had a sensitivity of 80% and specificity of 81% for predicting grade 2 or 3 diastolic dysfunction.

CONCLUSIONS

The late diastolic peak longitudinal strain rate correlates with the severity of diastolic dysfunction in patients undergoing cardiac surgery.

An echocardiographic study of breed-specific reference ranges in healthy French Bulldogs

Echocardiography is a standard diagnostic tool for assessment of cardiac functions and cardiovascular diseases in dogs, however published echocardiographic measurements have varied widely based on dog breeds. The objective of this prospective reference interval study was to provide breed-specific echocardiographic values for healthy French Bulldogs. A total of 42 healthy French Bulldogs of both sexes (23 females and 19 males) were sampled. Furthermore, measurements for a control group (n = 16) were also conducted in four other dog breeds (Cocker Spaniel [n = 2], Cavalier King Charles Spaniel [n = 4], Terrier [n = 5], and Crossbreed [n = 5]). Standard M-mode, two-dimensional (2D), pulse wave (PW) Doppler, and tissue Doppler imaging (TDI) echocardiographic measurements were obtained from healthy French Bulldogs. The M-mode echocardiographic data obtained from French Bulldogs were compared to the data obtained from the control group. The left ventricular internal dimension at end-diastole (LVIDd; cm)/body surface area (BSA) (m² ) ratio for the study group was 3.35/0.53 = 6.32. Left ventricular measurements for French bulldogs and internal dimension at end-systole (21.23 ± 3.50 mm) and at end-diastole (33.50 ± 4.12 mm) were found to be significantly higher (P < .001) compared to control group values (left ventricular internal dimension at end-systole [LVIDs]; 17.46 ± 2.85 mm, LVIDd; 27.16 ± 4.20 mm, respectively). A significantly positive correlation in the French Bulldog group was noted between body weight and M-mode measurements (EPSS, IVSd, IVSs, LVIDd, LVIDs, and LVPWd). French bulldogs had a greater systolic and diastolic left ventricular volume than the control group. As a result, values reported in this study could be used as specific reference ranges in French Bulldogs.

User-Intended Doppler Measurement Type Prediction Combining CNNs With Smart Post-Processing

Spectral Doppler measurements are an important part of the standard echocardiographic examination. These measurements give insight into myocardial motion and blood flow, providing clinicians with parameters for diagnostic decision making. Many of these measurements are performed automatically with high accuracy, increasing the efficiency of the diagnostic pipeline. However, full automation is not yet available because the user must manually select which measurement should be performed on each image. In this work, we develop a pipeline based on convolutional neural networks (CNNs) to automatically classify the measurement type from cardiac Doppler scans. We show how the multi-modal information in each spectral Doppler recording can be combined using a meta parameter post-processing mapping scheme and heatmaps to encode coordinate locations. Additionally, we experiment with several architectures to examine the tradeoff between accuracy, speed, and memory usage for resource-constrained environments. Finally, we propose a confidence metric using the values in the last fully connected layer of the network and show that our confidence metric can prevent many misclassifications. Our algorithm enables a fully automatic pipeline from acquisition to Doppler spectrum measurements. We achieve 96% accuracy on a test set drawn from separate clinical sites, indicating that the proposed method is suitable for clinical adoption.

Prognostic Value and Interplay Between Myocardial Tissue Velocities in Patients Undergoing Coronary Artery Bypass Grafting

Early diastolic tissue velocity (e') by tissue Doppler imaging represents an early marker of left ventricular (LV) dysfunction in ischemic heart disease. We assessed the value of e' for predicting mortality in patients undergoing coronary artery bypass grafting (CABG). We retrospectively investigated patients treated with CABG between 2006-2011. Before surgery, all patients underwent an echocardiogram with tissue Doppler imaging to measure tissue velocities: systolic (s'), e', and late diastolic (a'). The primary outcome was all-cause mortality. Survival analysis was applied. Improvement of EuroSCORE-II was assessed by net reclassification index. Of 660 patients, 72 (11%) died during a median follow-up time of 3.8 years. Mean age was 68 years, LVEF 50%, and 84% were men. All tissue velocities showed a significant negative association with outcome and e' provided highest Harrell's C-statistics (c-stat=0.68). After multivariable adjustment for EuroSCORE-II, LV hypertrophy, LV internal diameter, and global longitudinal strain, declining e' was associated with a higher risk of mortality (HR=1.35 (1.12 to 1.61), p = 0.001, per 1cm/s absolute decrease). LVEF≤40% modified the relationship between both s' and e' and outcome (p for interaction=0.021 and 0.024, respectively), such that neither predicted mortality when LVEF was ≤40%. In patients with LVEF>40%, only e' remained a predictor after multivariable adjustments (HR=1.36 (1.10 to 1.69), p = 0.005, per 1cm/s absolute decrease). A net reclassification index improvement of 0.14 was observed when adding global e' to the EuroSCORE-II. In conclusion, e' is an independent predictor of all-cause mortality in patients undergoing CABG, especially in patients with LVEF>40%, and improves the predictive value of EuroSCORE-II.

Impact of surgical aortic valve replacement on global and regional longitudinal strain across four flow gradient patterns of severe aortic stenosis

To evaluate the impact of surgical aortic valve replacement (SAVR) on global (GLS) and regional longitudinal strain (RLS) across four flow-gradient patterns of severe aortic stenosis (AS) 3 months after surgery. A total of 103 patients with severe AS (aortic valve area < 1.0 cm²) were examined by speckle tracking echocardiography the day before SAVR and at 3-months follow-up. Patients were stratified into four flow-gradient patterns by stroke volume index (>35 mL/m² vs. ≤35 mL/m²) and mean transaortic gradients (>40 mmhg vs. ≤40 mmhg): normal-flow, high gradient (NF/HG); low-flow, high gradient (LF/HG); normal-flow, low gradient (NF/LG); low-flow, low gradient (LF/LG). Strain analysis comprised GLS and RLS at a basal (BLS), mid-ventricular (MLS) and apical level (ALS). Patients with high gradients improved GLS (NF/HG: 16.1 ± 3.5 % vs. 17.3 ± 3.4 %, p = 0.03 and LF/HG: 15.4 ± 3.6 % vs. 16.9 ± 3.1 %, p = 0.03), BLS (NF/HG: 12.7 ± 3.1 % vs. 14.2 ± 3.1 %, p = 0.003 and LF/HG: 11.4 ± 3.2 % vs. 13.8 ± 2.7 %, p = 0.005) and MLS (NF/HG: 15.4 ± 3.3 % vs. 16.5 ± 3.3 %, p = 0.04 and LF/HG: 14.5 ± 3.1 % vs. 16.2 ± 2.7 %, p = 0.01) whereas patients with low gradients showed no improvements three months after SAVR. ALS did not change significantly in any group. Patients with high gradients demonstrated a reduction in left ventricular (LV) mass index (p < 0.001) and N-terminal pro-Brain Natriuretic Peptide levels (p < 0.001) following SAVR in contrast to patients with low gradients. Patients with high gradient severe AS improve GLS and RLS three months after SAVR with concomitant reduction of LV mass and neurohormonal activation whereas patients with low gradients do not improve longitudinal strain, LV mass or neurohormonal activation.

Effect of Adenotonsillectomy on Cardiac Function in Children Age 5-13 Years With Obstructive Sleep Apnea

Changes in left ventricular structure and function have been previously described in children with obstructive sleep apnea (OSA). We aimed to determine if these structural and functional cardiac changes are reversible after treatment of OSA with adenotonsillectomy. Children aged 5 to 13 years with OSA and matched healthy controls were recruited. Adenotonsillectomy occurred within 1 month after diagnosis. Echocardiography and polysomnography were repeated postoperatively. Linear mixed models were fitted to echocardiography measures at baseline and follow-up to assess the effect of OSA on cardiac structure and function. These adjusted for age, gender, race, body mass index, systolic, and diastolic blood pressure. The study sample included 373 children, 199 with OSA and 174 healthy controls. In the control group, 114 children completed the study and 112 completed the study in the OSA group. Children with OSA had reduced diastolic function, lower systolic function, and greater left ventricular mass index at baseline compared with healthy controls (all p < 0.05). Measures of active relaxation, elastic recoil and lengthening of the left ventricle impacted overall diastolic function; each of these worsened with increasing OSA severity. Postoperatively, diastolic function improved in children with OSA compared with controls. There were not significant changes in LV mass index or geometry. In conclusion, children with OSA have impaired left ventricular relaxation during diastole indicating early stage diastolic dysfunction. Adenotonsillectomy for OSA signficantly improved diastolic function. Left ventricular remodeling did not change with improvement of OSA.

Effect of long-term glucocorticoid therapy on cardiac functions in children with congenital adrenal hyperplasia

BACKGROUND

Glucocorticoids play an important role in cardiac physiology. Chronic exposure and higher doses may cause adverse effects on the myocardium, especially in young patients receiving long-term therapy.

OBJECTIVE

To assess cardiac function in children with congenital adrenal hyperplasia (CAH) and its relation to glucocorticoid dose and therapy duration.

METHODS

Forty-seven patients with CAH due to 21-hydroxylase deficiency were compared to 47 controls. Patients were subdivided according to treatment duration (Group A: less than 6 years, Group B: more than 6 years). Mean daily glucocorticoid and cumulative glucocorticoid doses were calculated. Echocardiography was performed for patients and controls to evaluate cardiac functions, chamber dimensions and tissue Doppler valvular status.

RESULTS

Compared to controls, patients had cardiac chamber hypertrophy reflected by higher M-mode dimensions. Patients had lower fractional shortening, defective ventricular relaxation, lower average mitral and tricuspid e´/a´ ratios (e´ early diastolic, a´ late diastolic) as well as s´ (systolic) velocities, higher average mitral E/e ratio and higher left ventricle TDI Tei index (P < .05). Group B had lower average mitral e´/a´ and tricuspid s´ velocities, and higher average mitral E/e ratio (P < .05). Cumulative glucocorticoid dose significantly correlated with different echocardiographic parameters.

CONCLUSION

Long-term glucocorticoid therapy even within the recommended therapeutic range adversely affects cardiac functions in children with 21-hydroxylase deficiency.

The potential effect of cardiac function on pulmonary hypertension, other risk factors, and its impact on survival in dialysis patients

INTRODUCTION

Pulmonary hypertension (PH) is a recently recognized as a complication of chronic kidney disease and end-stage renal disease. The pathogenesis of pulmonary hypertension in this group of patients is not fully understood, probably due to the interaction of multiple aspects of the altered cardiovascular physiology and also hormonal and metabolic disorders. The present study aimed to determine the prevalence of PH, correlation with cardiac function and other risk factors and its impact of survival in chronic hemodialysis and peritoneal dialysis patients.

METHODS

We studied 125 stable hemodialysis and peritoneal patients (females 40%, mean age 52.42 ± 11.88 years) on renal replacement therapy (RRT) for more than 3 months with a follow up 2 years. Demographic information, clinical characteristics, blood test, and thoroughly echocardiographic evaluation at the optimal dry weight were collected. After conventional echocardiographic examination, tissue Doppler echocardiographic (TDE) examination was performed to evaluate global and regional myocardial systolic as well as diastolic function, and pulmonary hypertension. PH was defined as systolic pulmonary artery pressure (sPAP) ≥ 35 mmHg. To rule out secondary PH, patients with pulmonary disease, collagen vascular disease, and volume overload at the time of echocardiography were excluded. Variables were compared between two groups-subjects with PH and non-PH. Logistic regression analysis was used to evaluate the risk factor for PH and its impact on survival.

RESULTS

According to the echocardiographic findings, PH was found in 28% (35 patients) of all patients. Mean PH was 33.46 ± 5.38 mmHg. The higher level of higher parathormone (PTH), C-reactive protein (CRP) and E/E' average, lower left ventricular ejection fraction (EF), peak systolic velocity at the lateral mitral annulus (MASa) and the peak systolic velocity at the lateral tricuspid annulus (TASa) were found predictor of PH. The cardiovascular mortality rate was 15.5%. Patients evaluated with PH have a significantly lower cardiovascular survival rate [Long Rank (Mantel-Cox) p = 0.0001]. In ROC analysis for CV mortality, the area under the curve (AUC) for PH and CRP was found 0.8; for LVM-I, E/E' and PP, AUC = 0.76; 0.75; 0.72 respectively while the inverse relationship was found with MASa and TASa with AUC = 0.66 and 0.95 respectively.

CONCLUSION

Our study shows that PH is frequent in dialysis patients. It is influenced by inflammation, CKD-MBD biomarkers associated with diastolic and also systolic left and right ventricle dysfunction. Pulmonary hypertension, inflammation, vascular stiffness, and left ventricular hypertrophy are interrelated and all contribute to cardiovascular morbidity and mortality among dialysis patients. Easy to implement, cardiac imaging at the bedside and in outpatient clinics offers a positive perspective in early diagnosis of cardiac abnormalities and immediate approach to this condition, so is highly recommended in the dialysis population.

Assessment of the Cardiac Functions Using Full Conventional Echocardiography with Tissue Doppler Imaging before and after Xylazine Sedation in Male Shiba Goats

The present study aimed to provide a complete conventional echocardiographic protocol in adult male Shiba goats by using two-dimensional, M-mode, Pulsed Wave Doppler, and tissue Doppler imaging (TDI) echocardiography, and to study concomitantly xylazine-induced alteration of cardiac functions in a highly sensitive species. For this purpose, 12 male Shiba goats were included and complete conventional echocardiography from the standard right and left parasternal views was carried to report the echocardiographic data in male Shiba goats, and also before and after xylazine (Pre-Xyl and Post-Xyl) administration (0.05 mg/IM/kg). Results revealed that the full echocardiographic protocol was feasible in all goats through different cardiac windows and good Doppler alignment was achieved with non-significant variability for assessment of the left ventricular dimensions, trans-pulmonary, trans-aortic, and trans-mitral blood flow. The TDI, which was not reported previously in goats, was successfully assessed from the standard left apical view and showed distinct systolic and diastolic patterns. Xylazine administration was found to significantly reduce heart rate, fractional shortening, and cardiac output as well as the Doppler hemodynamic parameters of the pulmonary artery, aortic and mitral inflows (p < 0.05). For TDI, the Post-Xyl group revealed a significant decrease in the myocardial velocities of the septal and lateral wall of the left ventricle. The present study provides, for the first time, complete data of conventional echocardiography in male goats using the full protocol, which is routinely used in pet's practice. Further, we illustrate in-depth the adverse effect of short-term sedative, xylazine, as used under field conditions and emphasize a simultaneous reduction in both systolic and diastolic cardiac function in goats based on full echocardiography assessment of the heart.

Prognostic Relevance of Left Ventricular Thrombus Motility: Assessment by Pulsed Wave Tissue Doppler Imaging

Pulsed wave tissue Doppler imaging (PW-TDI) easily detects motion of cardiac structures. Hence, PW-TDI could be of value for assessing potentially cardioembolic masses. We sought to evaluate the prognostic value of left ventricular (LV) thrombus mobility assessed by PW-TDI. In 83 consecutive patients with echocardiographically detected LV thrombi, PW-TDI echocardiographic study was performed. At 1-year follow-up, the composite of major adverse cardiovascular events (MACE) defined as all-cause mortality plus hospitalizations for stroke/systemic embolism was evaluated. Seventy-two patients (77.1 ± 13.1 year/old, 32 males) were studied. All thrombi were located at the LV apex. At 1-year follow-up, 17 cardioembolic events occurred. By univariable Cox analysis, variables associated with MACE were heart rate (hazard ratio: 1.02, 95% CI: 1.00-1.05; P = .03), thrombi with mobile free edge (hazard ratio: 3.25, 95% CI: 1.25-8.44; P = .01), hypoechoic thrombi (hazard ratio: 2.86, 95% CI: 1.10-7.42; P = .03), and mass peak antegrade velocity (Va) ≥10 cm/s (hazard ratio: 8.79, 95% CI: 2.00-38.5; P = .004). By multivariable analysis, thrombi with mobile free edge (hazard ratio: 3.54, 95% CI: 1.23-10.2; P = .02), and mass peak Va ≥10 cm/s (hazard ratio: 7.97, 95% CI: 1.60-39.6; P = .01) retained statistical significance. Mass peak Va ≥10 cm/s predicted the composite end point with 94% sensitivity and 85% specificity (area under the curve = 0.86). In conclusion, PW-TDI allows objective prognostication of LV thrombi embolic risk.

Prediabetes, heart mechanics, and echocardiography: A narrative review

Prediabetes is a dysglycemic state that affects many around the world and is a known risk factor for the occurrence of type 2 diabetes mellitus in the future, accompanied by vascular complications. Evidence abounds regarding myocardial involvement in prediabetes. We herein review studies having applied tissue Doppler imaging or speckle-tracking echocardiography to evaluate myocardial function in subjects with prediabetes to depict a picture of cardiac mechanics in individuals with prediabetes in comparison with patients suffering from diabetes mellitus and individuals in the normoglycemic state. Finally, we present the detrimental effects of prediabetes on cardiac mechanics.

Echocardiographic reference intervals with allometric scaling of 823 clinically healthy rhesus macaques (Macaca mulatta)

BACKGROUND

Echocardiography is commonly used for assessing cardiac structure and function in various species including non-human primates. A few previous studies reported normal echocardiographic reference intervals of clinically healthy rhesus macaques under sedation. However, these studies were under-powered, and the techniques were not standardized. In addition, body weight, age, and sex matched reference intervals should be established as echocardiographic measurements are commonly influenced by these variables. The purpose of this study was to establish reference intervals for complete echocardiographic parameters based on a large cohort of clinically healthy rhesus macaques with wide ranges of weight and age distributions using allometric scaling.

RESULTS

A total of 823 rhesus macaques (ages 6 months to 31 years old; body weights 1.4 to 22.6 kg) were enrolled. Of these rhesus macaques, 421 were males and 402 were females. They were assessed with a complete echocardiographic examination including structural and functional evaluation under sedation with ketamine hydrochloride. The reference intervals of the key echocardiographic parameters were indexed to weight, age, and sex by calculating the coefficients of the allometric eq. Y = aM^b. On correlation matrix, body weight, age, sex, and heart rate were significantly correlated with various echocardiographic parameters and some of the parameters were strongly correlated with body weight and age. Multiple regression analysis revealed that heart rate and body weight statistically significantly predicted several echocardiographic parameters. Valve regurgitation including tricuspid, aortic, pulmonic, and mitral regurgitations without other cardiac structural and functional abnormalities are common in clinically healthy rhesus macaques under ketamine sedation.

CONCLUSIONS

In this study, the reference intervals of echocardiographic parameters were established by performing complete echocardiographic examinations on a large number of clinical healthy rhesus macaques. In addition, allometric scaling was performed based on their weight, and further indexed to age and sex. These allometrically scaled reference intervals can be used to accurately evaluate echocardiographic data in rhesus macaques and diagnose structural and functional evidence of cardiac disease.

The use of ultrasound to assess aortic biomechanics: Implications for aneurysm and dissection

Arterial stiffening, which occurs when conduit arteries thicken and lose elasticity, has been associated with cardiovascular disease and increased risk for future cardiovascular events. Specifically, aortic stiffening plays a large role in the pathogenesis of vascular diseases, such as aneurysm formation and dissection. Current parameters used to assess risk of aortic rupture include absolute diameter and growth rate. However, these properties lack the reliability required to accurately risk-stratify patients. As with any elastic conduit, it is important to assess the biomechanical properties of the aorta in order to assess cardiovascular risk and prevent disease progression. There are several invasive and noninvasive methods by which stiffness of the large arteries can be assessed. Of particular interest are ultrasound-based methods, such as tissue Doppler imaging and speckle-tracking echocardiography, due to their noninvasive and feasible nature. In this review, we summarize studies demonstrating utility of noninvasive ultrasound imaging methods for measuring aortic biomechanics for the assessment and management of aortic aneurysms.

A comparison of cardiac structure and function between female powerlifters, fitness-oriented athletes, and sedentary controls

AIM

To compare echocardiographic parameters between female powerlifters, fitness-oriented athletes, and sedentary controls.

METHODS

A between-subject, cross-sectional experimental design was adopted. Echocardiographic parameters were measured in female powerlifters (n = 10; progressive overload 60%-95% of 1 repetition maximum [RM]), fitness-oriented athletes (n = 10; 50%-70% of 1-RM), and sedentary control subjects (n = 10). Comparisons were made with Kruskal-Wallis tests, one-way analyses of variance, and eta-squared (η² ) interpreted as small = 0.01-0.06, moderate = 0.061-0.14, and large >0.14.

RESULTS

Large differences (P > .05) were observed between resistance-trained groups and sedentary controls, whereby relative wall thickness (RWT) and left ventricular (LV) index were greater in powerlifters (RWT: 0.40 ± 0.05, η²  = 0.15; LV index: 95.6 ± 13.6 g/m² , η²  = 0.15) and fitness-oriented athletes (RWT: 0.40 ± 0.05, η²  = 0.15; LV index: 97.9 ± 14.2 g/m² , η²  = 0.20) compared to sedentary controls (RWT: 0.36 ± 0.05; LV index: 85.9 ± 10.3 g/m² ). Large differences were observed in intra-ventricular septal wall thickness (ISWT) and late diastolic velocity (a') between groups, whereby powerlifters exhibited lower a' (8.6 ± 1.2 cm/s) compared to fitness-oriented athletes (9.9 ± 0.9 cm/s, η²  = 0.26, P = .04) and sedentary controls (9.6 ± 0.9 cm/s, η²  = 0.19, P > .05), while fitness-oriented athletes exhibited greater ISWT (10.1 ± 0.7 mm) compared to sedentary controls (9.4 ± 1.0 mm, η²  = 0.16, P > .05).

CONCLUSIONS

Differences in cardiac structure between powerlifters, fitness-oriented athletes, and sedentary controls suggest specific cardiac remodeling may occur in response to resistance training, without impairment of cardiac function.

Echocardiographic reference ranges for normal cardiac Doppler data in healthy Turkish population: ECHO-DOP-TR Trial

AIM

Doppler echocardiography has become the standard imaging modality for diastolic function and provides pathophysiological insight into systolic and diastolic heart failure. In this study, we aimed to obtain normal echocardiographic Doppler parameters of healthy Turkish population.

METHODS

Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination and The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used for echocardiographic Doppler measurements.

RESULTS

A total of 967 healthy participants were enrolled in this study after applying exclusion criteria. Echocardiographic examination was obtained from all subjects following predefined protocols. Mitral E wave velocity and E/A ratio were higher in females and decreased progressively in advancing ages. E wave deceleration time and A wave velocity were increased with aging. Assessment of tissue Doppler velocities showed that left ventricular lateral e', septal e', and septal s' were higher in younger subjects and in females. E/e' ratio was increased progressively with advancing decades. Right ventricular e' and s' were decreased but a' was increased with increasing age. Septal e' lower than 8 cm/s was 1.9% in the fifth decade and 13.7% in ages older than 50 years. The E/e' ratio greater than 15 (and also 13) was not found.

CONCLUSION

This study, for the first time, provides echocardiographic reference ranges for normal cardiac Doppler data in healthy Turkish population which will be useful in routine clinical practice as well as in future clinical trials.

Soluble ST2 and CXCL-10 may serve as biomarkers of subclinical diastolic dysfunction in SLE and correlate with disease activity and damage

Objective

Subclinical myocardial dysfunction has been reported to occur early in systemic lupus erythematous (SLE). The study aim was to search for biomarkers of subclinical myocardial dysfunction which may correlate with disease activity in SLE patients.

Methods

This is a prospective, controlled, cross-sectional study of 57 consecutive patients with SLE and 18 controls. Serum samples were obtained to determine serum soluble ST2 (sST2), CXCL-10 and high-sensitivity troponin (hs-troponin) levels. All participants underwent an echocardiographic tissue Doppler study.

Results

sST2, CXCL-10 and hs-troponin levels were higher in patients with higher SLE disease activity (SLEDAI). sST2 and CXCL-10 levels were higher in patients with more disease damage as measured by the SLE damage index. Measures of diastolic dysfunction, as assessed by echocardiographic tissue Doppler negatively correlated with log CXCL-10: including E/A; E/e′lateral and E/e′septal, while E/e′ positively correlated with CXCL-10. Diastolic dysfunction parameters also correlated with log sST2 levels, a negative correlation was seen with E/e′lateral and a positive correlation was seen with E/e′. Systolic dysfunction parameters positively correlated with hs-troponin: LVED, LVES, IVS, LVMASS and LVMASS index. In a multivariate analysis, sST2 and CXCL-10 were found to be significantly different in SLE vs. healthy controls, independent of each other and independent of cardiovascular risk factors.

Conclusions

Soluble ST2 and CXCL-10 are markers of disease activity and accrued damage in SLE and may serve as sensitive biomarkers for detection of subclinical diastolic dysfunction, independent of traditional cardiovascular risk factors.

Speckle- Tracking Echocardiography for the Staging of Diastolic Dysfunction: The Correlation Between Strain-Based Indices and the Severity of Left Ventricular Diastolic Dysfunction

OBJECTIVES

Left ventricular diastolic function can be assessed by various methods. Tissue Doppler imaging is among the most commonly used techniques. However, this imaging is angle- dependent, affected by loading conditions, and susceptible to myocardial tethering. Speckle- tracking echocardiography also can measure strain-based indices to assess diastolic function, and it has fewer limitations than tissue Doppler imaging. Using speckle- tracking echocardiography, the authors evaluated the correlation between the stage of diastolic dysfunction and strain-based indices in patients undergoing cardiac surgery to determine whether strain-based indices can be used intraoperatively to identify the extent of left ventricular diastolic dysfunction.

DESIGN

Retrospective clinical study.

SETTING

Single university hospital.

PARTICIPANTS

Fifty-eight patients undergoing cardiac surgery (December 2017 to December 2019).

INTERVENTIONS

None. Measurement and Main Result: Preoperative echocardiographic reports and intraoperative echocardiographic images of the participants were studied. The correlation between the stage of left ventricular diastolic dysfunction and strain-based indices (including early diastolic peak longitudinal strain and tissue deceleration time) were evaluated. Early diastolic peak longitudinal strain rate significantly correlated with the stage of diastolic dysfunction (r = -0.7 and p < 0.0001). Tissue deceleration time significantly correlated with the stage of diastolic dysfunction in patients with diastolic abnormality (r = -0.4 and p = 0.02). When patients with normal diastolic function were included, this correlation was not significant (r= -0.25 and p = 0.05).

CONCLUSIONS

Intraoperatively measured early diastolic peak longitudinal strain rate and tissue deceleration time correlated with the severity of diastolic dysfunction in patients undergoing cardiac surgery.

Investigating the estimation of cardiac time intervals using gyrocardiography

OBJECTIVE

Assessment of cardiac time intervals (CTIs) is essential for monitoring cardiac performance. Recently, gyrocardiography (GCG) has been introduced as a non-invasive technology for cardiac monitoring. GCG measures the chest's angular precordial vibrations caused by myocardium wall motion using a gyroscope sensor attached to the sternum. In this study, we investigated the accuracy and reproducibility of estimating CTIs from the GCG recordings of 50 adults.

APPROACH

We proposed five fiducial points for the GCG waveforms associated with the opening and closure of aortic and mitral valves. Two annotators annotated the suggested points on each cardiac cycle. The points were compared to the corresponding opening and closing of cardiac valves delineated on Tissue Doppler imaging (TDI) recordings. The fiducial points were annotated on seismocardiography (SCG) and impedance cardiography (ICG) signals recorded simultaneously.

MAIN RESULTS

For estimating the timing of mitral valve closure, aortic valve opening, aortic valve closure, and mitral valve opening, 40%, 67%, 75%, and 70% of GCG annotations fell in the corresponding echocardiography ranges, respectively. The results showed moderate-to-excellent (r = 0.4-0.92; p-value < 0.01) correlation between the measured and the reference CTls. A myocardial performance index (Tei index) adapted using joint GCG and SCG resulted in a moderate correlation (r = 0.4; p-value < 0.001).

SIGNIFICANCE

The findings showed that the CTIs can be easily measured using GCG. Also, we found that using SCG and GCG recordings together could provide an opportunity to estimate CTIs more accurately, and make it possible to calculate the Tei index as an indicator of myocardial performance.

Associations of inflammatory markers with impaired left ventricular diastolic and systolic function in collagen-induced arthritis

Background

High-grade inflammation may play a pivotal role in the pathogenesis of left ventricular (LV) dysfunction. Evidence to support a role of systemic inflammation in mediating impaired LV function in experimental models of rheumatoid arthritis (RA) remains limited. The aim of the present study was to determine the effects of high-grade systemic inflammation on LV diastolic and systolic function in collagen-induced arthritis (CIA).

Methods

To induce CIA, bovine type-II collagen emulsified in incomplete Freund’s adjuvant was injected at the base of the tail into 21 three-month old Sprague Dawley rats. Nine-weeks after the first immunisation, LV function was assessed by pulsed Doppler, tissue Doppler imaging and Speckle tracking echocardiography. Cardiac collagen content was determined by picrosirius red staining; circulating inflammatory markers were measured using ELISA.

Results

Compared to controls (n = 12), CIA rats had reduced myocardial relaxation as indexed by lateral e’ (early diastolic mitral annular velocity) and e’/a’ (early-to-late diastolic mitral annular velocity) and increased filling pressures as indexed by E/e’. No differences in ejection fraction and LV endocardial fractional shortening between the groups were recorded. LV global radial and circumferential strain and strain rate were reduced in CIA rats compared to controls. Higher concentrations of circulating inflammatory markers were associated with reduced lateral e’, e’/a’, radial and circumferential strain and strain rate. Greater collagen content was associated with increased concentrations of circulating inflammatory markers and E/e’.

Conclusion

High-grade inflammation is associated with impaired LV diastolic function and greater myocardial deformation independent of haemodynamic load in CIA rats.

Automatic quantification of left ventricular function by medical students using ultrasound

BACKGROUND

Automatic analyses of echocardiograms may support inexperienced users in quantifying left ventricular (LV) function. We have developed an algorithm for fully automatic measurements of mitral annular plane systolic excursion (MAPSE) and mitral annular systolic (S') and early diastolic (e') peak velocities. We aimed to study the influence of user experience of automatic measurements of these indices in echocardiographic recordings acquired by medical students and clinicians.

METHODS

We included 75 consecutive patients referred for echocardiography at a university hospital. The patients underwent echocardiography by clinicians (cardiologists, cardiology residents and sonographers), who obtained manual reference measurements of MAPSE by M-mode and of S' and e' by colour tissue Doppler imaging (cTDI). Immediately after, each patient was examined by 1 of 39 medical students who were instructed in image acquisition on the day of participation. Each student acquired cTDI recordings from 1 to 4 patients. All cTDI recordings by students and clinicians were analysed for MAPSE, S' and e' using a fully automatic algorithm. The automatic measurements were compared to the manual reference measurements.

RESULTS

Correct tracking of the mitral annulus was feasible in 50 (67%) and 63 (84%) of the students' and clinicians' recordings, respectively (p = 0.007). Image quality was highest in the clinicians' recordings. Mean difference ± standard deviation of the automatic measurements of the students' recordings compared to the manual reference was - 0.0 ± 2.0 mm for MAPSE, 0.3 ± 1.1 cm/s for S' and 0.6 ± 1.4 cm/s for e'. The corresponding intraclass correlation coefficients for MAPSE, S' and e' were 0.85 (good), 0.89 (good) and 0.92 (excellent), respectively. Automatic measurements from the students' and clinicians' recordings were in similar agreement with the reference when mitral annular tracking was correct.

CONCLUSIONS

In case of correct tracking of the mitral annulus, the agreement with reference for the automatic measurements was overall good. Low image quality reduced feasibility. Adequate image acquisition is essential for automatic analyses of LV function indices, and thus, appropriate education of the operators is mandatory. Automatic measurements may help inexperienced users of ultrasound, but do not remove the need for dedicated education and training.

Association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities

Aim

This study examines the association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities.

Material and methods

We performed retrospective analysis of clinical, peripheral venous Duplex and tricuspid Doppler (early diastolic inflow E-wave, late diastolic inflow A-wave, ratios of E to A waves, early diastolic annular e′-wave, late diastolic annular a′-wave and systolic annular s′- wave) data of 85 patients, 133 legs with primary varicose veins.

Results

We found following significant (p-value < 0.05) associations between tricuspid Doppler and clinical presentation of chronic venous disease and primary varicose veins: Clinical Etiological Anatomical Pathophysiological clinical class influenced late diastolic inflow velocities (C6 class A-wave +11.2 cm/s or +27% in comparison with C2), late diastolic annular velocities (C6 class a′-wave +3.3 cm/s or +22% in comparison with C2), systolic annular velocities (C6 class s′-wave +3.7 cm/s or +27% in comparison with C2) and E/A ratios (C6 class E/A ratio −0.22 or −21% in comparison with C2). Recurrent varices in comparison with previously untreated are associated with significantly lower late diastolic inflow velocities (A-wave −4.4 cm/s or −9%) and preserved E/A ratios. Age significantly influenced tricuspid Doppler (E-, A-, e′-, a′-waves and E/A ratios) in patients with chronic venous disease.

Conclusion

Clinical presentation of primary varicose veins and chronic venous disease can be associated with the right heart diastolic function: C6 Clinical Etiological Anatomical Pathophysiological class in comparison with C2 is associated with increased right ventricular filling and impaired ventricular relaxation – right heart diastolic dysfunction; recurrent varices in comparison with previously untreated are associated with reduced right ventricular filling and preserved right heart diastolic function. Older age is the most important risk factor for varicose veins and chronic venous disease possible due to significant changes in right ventricular filling and in right heart diastolic function with age.

Subclinical Cardiac Dysfunction in Childhood Cancer Survivors on 10-Years Follow-Up Correlates With Cumulative Anthracycline Dose and Is Best Detected by Cardiopulmonary Exercise Testing, Circulating Serum Biomarker, Speckle Tracking Echocardiography, and Tissue Doppler Imaging

Background: Survivors of childhood cancer are at risk for anthracycline- and/or radiotherapy-induced cardiotoxicity. Aims: The aim of this study was to assess clinical, laboratory, and imaging parameters of subclinical cardiovascular disease in childhood cancer survivors. Methods: Patients underwent cardiopulmonary exercise test (CPET), laboratory testing, transthoracic echocardiography (TTE) with tissue doppler imaging (TDI) and speckle tracking. A subset of patients also underwent cardiovascular magnetic resonance imaging (CMR). Findings were correlated to cumulative anthracycline and exposure to mediastinal irradiation during cancer treatment. In a subgroup analysis, TTE and CMR findings were compared to data from 40 gender- and age-matched patients with childhood onset hypertrophic cardiomyopathy (HCM). Results: Cardiac evaluation was performed in 79 patients (43 males) at 11.2 ± 4.5 years after cancer treatment. Oncologic diagnosis at a median age of 12.0 years was Hodgkin lymphoma in 20, sarcoma in 17, acute leukemia in 24, relapse leukemia in 10, and others in 8 patients. Cumulative anthracycline dose exceeded 300 mg/m² in 28 patients. Twenty six patients also received mediastinal irradiation. Decreased peak respiratory oxygen uptake in % predicted on CPET, increased levels of N-terminal pro-brain natriuretic peptide (NTproBNP), increased global longitudinal strain on TTE speckle tracking, and diastolic dysfunction on TDI were the most prominent findings on detailed cardiology follow-up. In contrast to HCM patients, childhood cancer survivors did not show left ventricular hypertrophy (LVPWd z-score median 0.9 vs. 2.8, p < 0.001), hyperdynamic systolic function on TTE (Ejection fraction 62 ± 7 vs. 72 ± 12%, p = 0.001), or fibrotic myocardial changes on CMR (Late gadolinium positive 0/13 vs. 13/36, p = 0.001; extracellular volume fraction 22 ± 2 vs. 28 ± 3, p < 0.001) at time of follow-up. There was no correlation between chest radiation exposure and abnormal cardiac findings. Cumulative anthracycline dose was the only significant independent predictor on multivariate analysis for any cardiovascular abnormality on follow-up (p = 0.036). Conclusion: Increasing cumulative anthracycline dose during cancer treatment correlates with subclinical cardiac dysfunction in childhood cancer survivors best detected by elevated cardiac serum biomarkers, decreased exercise capacity on CPET, and abnormalities on echocardiographic speckle tracking and TDI.