Fast Measurement of Left Ventricular Mass With Real-Time Three-Dimensional Echocardiography

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.

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.

Validating real-time three-dimensional echocardiography against cardiac magnetic resonance, for the determination of ventricular mass, volume and ejection fraction: a meta-analysis

INTRODUCTION

Real-time three-dimensional echocardiography (RT3DE) is currently being developed to overcome the challenges of two-dimensional echocardiography, as it is a much cheaper alternative to the gold standard imaging method, cardiac magnetic resonance (CMR). The aim of this meta-analysis is to validate RT3DE by comparing it to CMR, to ascertain whether it is a practical imaging method for routine clinical use.

METHODS

A systematic review and meta-analysis method was used to synthesise the evidence and studies published between 2000 and 2021 were searched using a PRISMA approach. Study outcomes included left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), left ventricular mass (LVM), right ventricular end-systolic volume (RVESV), right ventricular end-diastolic volume (RVEDV) and right ventricular ejection fraction (RVEF). Subgroup analysis included study quality (high, moderate), disease outcomes (disease, healthy and disease), age group (50 years old and under, over 50 years), imaging plane (biplane, multiplane) and publication year (2010 and earlier, after 2010) to determine whether they explained the heterogeneity and significant difference results generated on RT3DE compared to CMR.

RESULTS

The pooled mean differences for were - 5.064 (95% CI - 10.132, 0.004, p > 0.05), 4.654 (95% CI - 4.947, 14.255, p > 0.05), - 0.783 (95% CI - 5.630, 4.065, p > 0.05, - 0.200 (95% CI - 1.215, 0.815, p > 0.05) for LVEF, LVM, RVESV and RVEF, respectively. We found no significant difference between RT3DE and CMR for these variables. Although, there was a significant difference between RT3DE and CMR for LVESV, LVEDV and RVEDV where RT3DE reports a lower value. Subgroup analysis indicated a significant difference between RT3DE and CMR for studies with participants with an average age of over 50 years but no significant difference for those under 50. In addition, a significant difference between RT3DE and CMR was found in studies using only participants with cardiovascular diseases but not in those using a combination of diseased and healthy participants. Furthermore, for the variables LVESV and LVEDV, the multiplane method shows no significant difference between RT3DE and CMR, as opposed to the biplane showing a significant difference. This potentially indicates that increased age, the presence of cardiovascular disease and the biplane analysis method decrease its concordance with CMR.

CONCLUSION

This meta-analysis indicates promising results for the use of RT3DE, with limited difference to CMR. Although in some cases, RT3DE appears to underestimate volume, ejection fraction and mass when compared to CMR. Further research is required in terms of imaging method and technology to validate RT3DE for routine clinical use.

Accuracy of Devereaux and Teichholz formulas for left ventricular mass calculation in different geometric patterns: comparison with cardiac magnetic resonance imaging

Left ventricular (LV) myocardial mass is important in the evaluation of cardiac remodeling and requires accurate assessment when performed on linear measurements in two-dimensional echocardiography (Echo). We aimed to compare the accuracy of the Devereaux formula (DEV) and the Teichholz formula (TEICH) in calculating LV myocardial mass in Echo using cardiac magnetic resonance (CMR) as the reference method. Based on preceding mathematical calculations, we identified primarily LV size rather than wall thickness as the main source of bias between DEV and TEICH in a retrospective derivation cohort (n = 1276). Although LV mass from DEV and TEICH were correlated with CMR, TEICH did not show a proportional bias as did DEV (- 2 g/m2 vs. + 22 g/m2). This could be validated in an independent prospective cohort (n = 226) with symptomatic non-ischemic heart failure. DEV systematically overestimated LV mass in all tiers of LV remodeling as compared to TEICH. In conclusion, the TEICH method accounts for the changes in LV geometry with increasing LV mass and thus better reflects the different pattern of LV remodeling than the DEV method. This has important clinical implications, as TEICH may be more appropriate for use in clinical practice, rather than DEV, currently recommended.

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.

Autonomic regulation therapy in chronic heart failure with preserved/mildly reduced ejection fraction: ANTHEM-HFpEF study results

BACKGROUND

Autonomic regulation therapy (ART) utilizing cervical vagus nerve stimulation (VNS) appeared to be safe and to improve autonomic tone, symptoms, and cardiac mechanical function in patients with symptomatic heart failure and reduced ejection fraction in the ANTHEM-HF Study. The ANTHEM-HFpEF Study is the first investigation to evaluate the safety and feasibility of ART in patients with symptomatic heart failure and preserved or mildly reduced ejection fraction (HFpEF, HFmrEF).

METHODS

This open-label interventional study enrolled 52 patients with HFpEF or HFmrEF, NYHA Class II-III, and LVEF ≥40%, who received stable guideline-directed medical therapy. All patients were successfully implanted with LivaNova VNS Therapy® system with an electrical lead surrounding the right cervical vagus nerve.

RESULTS

Adverse event incidence was low. At 12 months, NYHA class (p < 0.0001), 6-min walk distance (p < 0.05), and quality of life (p < 0.0001) were improved. Cardiac mechanical function measures were normal at baseline, except for left ventricular mass index in women and E/e' ratio in all patients, which were elevated at baseline, and were unchanged by ART. Autonomic tone and reflexes improved, indicated by 29% decrease in low-frequency/high-frequency heart rate variability to normal levels (p = 0.028) and by increased heart rate turbulence slope (p = 0.047). T-wave alternans (p = 0.001) and T-wave heterogeneity (p = 0.001) were reduced from abnormal to normal ranges. Nonsustained ventricular tachycardia incidence decreased (p = 0.027).

CONCLUSIONS

ART appeared well-tolerated and safe in patients with HFpEF or HFmrEF. Chronic ART did not alter mechanical function measures but was associated with improved heart failure symptoms, exercise tolerance, autonomic tone, and cardiac electrical stability.

CLINICAL TRIAL REGISTRY

Autonomic Neural Regulation Therapy to Enhance Myocardial Function in Heart Failure with Preserved Ejection Fraction [ClinicalTrials.gov #NCT03163030, registered 05/22/2017].

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.

Impact of Metabolic Syndrome on Left Ventricular Deformation and Myocardial Energetic Efficiency Compared Between Women and Men: An MRI Study

BACKGROUND

Metabolic and hemodynamic alterations in metabolic syndrome (MetS) can cause a reduced myocardial energetic efficiency (MEE). Indexed MEE (MEEi), as a simple estimate of MEE, is emerging as a novel and useful imaging parameter.

PURPOSE

To investigate the impact of MetS on MEE and systolic myocardial strain and to assess any sex difference.

STUDY TYPE

Retrospective.

POPULATION

A total of 161 patients with MetS (female: n = 82, 52.2 ± 11.7 years; male: n = 79, 51.8 ± 10.6 years) and 77 healthy subjects (female: n = 46, 52.7 ± 8.2 years; male: n = 31, 54.1 ± 11.2 years). Patients with left ventricular (LV) ejection fraction <50% were excluded.

FIELD STRENGTH/SEQUENCE

A 3.0 T; balanced steady-state free precession sequence.

ASSESSMENT

LV volumes and mass (LVM) and global longitudinal strain (GLS) were obtained by MRI. Stroke volume (SV) divided by HR was used as a surrogate measure of MEE and normalized to LVM (MEEi).

STATISTICAL TESTS

Student's t-test or Mann-Whitney U-test; Multivariable linear regression (coefficient of determination, R² ). P < 0.05 was considered statistically significant.

RESULTS

For both males and females, MEEi and GLS were lower in MetS patients than in the normal controls. Among MetS patients, men had significantly higher LVM (59.7 ± 13.4 g/m² vs. 48.8 ± 11.3 g/m² ) and significantly lower MEEi (0.68 ± 0.23 mL/g/s vs. 0.84 ± 0.23 mL/g/s) and GLS (-11.7% ± 2.8% vs. -13.9% ± 2.7%) than women. After adjustment for clinical variables, male gender (β = -0.291) was found to be inversely correlated with MEEi. Multivariable analysis showed that MEEi (β = 0.454) were independently associated with GLS (adjusted R²  = 0.454) after adjustment for clinical and other MRI parameters.

DATA CONCLUSION

MEEi was significantly impaired in MetS without overt systolic dysfunction. There was a sex difference regarding the cardiac alterations in MetS, with men having significantly lower MEEi and GLS and significantly higher LVM than women. Further, MEEi was independently associated with GLS.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Generalizability and quality control of deep learning-based 2D echocardiography segmentation models in a large clinical dataset

Use of machine learning (ML) for automated annotation of heart structures from echocardiographic videos is an active research area, but understanding of comparative, generalizable performance among models is lacking. This study aimed to (1) assess the generalizability of five state-of-the-art ML-based echocardiography segmentation models within a large Geisinger clinical dataset, and (2) test the hypothesis that a quality control (QC) method based on segmentation uncertainty can further improve segmentation results. Five models were applied to 47,431 echocardiography studies that were independent from any training samples. Chamber volume and mass from model segmentations were compared to clinically-reported values. The median absolute errors (MAE) in left ventricular (LV) volumes and ejection fraction exhibited by all five models were comparable to reported inter-observer errors (IOE). MAE for left atrial volume and LV mass were similarly favorable to respective IOE for models trained for those tasks. A single model consistently exhibited the lowest MAE in all five clinically-reported measures. We leveraged the tenfold cross-validation training scheme of this best-performing model to quantify segmentation uncertainty. We observed that removing segmentations with high uncertainty from 14 to 71% studies reduced volume/mass MAE by 6-10%. The addition of convexity filters improved specificity, efficiently removing < 10% studies with large MAE (16-40%). In conclusion, five previously published echocardiography segmentation models generalized to a large, independent clinical dataset-segmenting one or multiple cardiac structures with overall accuracy comparable to manual analyses-with variable performance. Convexity-reinforced uncertainty QC efficiently improved segmentation performance and may further facilitate the translation of such models.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

A new method to quantify left ventricular mass by 2D echocardiography

Increased left ventricular mass (LVM) is a strong independent predictor for adverse cardiovascular events, but conventional echocardiographic methods are limited by poor reproducibility and accuracy. We developed a novel method based on adding the mean wall thickness from the parasternal short axis view, to the left ventricular end-diastolic volume acquired using the biplane model of discs. The participants (n = 85) had various left ventricular geometries and were assessed using echocardiography followed immediately by cardiac magnetic resonance, as reference. We compared our novel two-dimensional (2D) method to various conventional one-dimensional (1D) and other 2D methods as well as the three-dimensional (3D) method. Our novel method had better reproducibility in intra-examiner [coefficients of variation (CV) 9% vs. 11–14%] and inter-examiner analysis (CV 9% vs. 10–20%). Accuracy was similar to the 3D method (mean difference ± 95% limits of agreement, CV): Novel: 2 ± 50 g, 15% vs. 3D: 2 ± 51 g, 16%; and better than the “linear” 1D method by Devereux (7 ± 76 g, 23%). Our novel method is simple, has considerable better reproducibility and accuracy than conventional “linear” 1D methods, and similar accuracy as the 3D-method. As the biplane model forms part of the standard echocardiographic protocol, it does not require specific training and provides a supplement to the modern echocardiographic report.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Advanced imaging tools for evaluating cardiac morphological and functional impairment in hypertensive disease

Arterial hypertension represents a systemic burden, and it is responsible of various morphological, functional and tissue modifications affecting the heart and the cardiovascular system. Advanced imaging techniques, such as speckle tracking and three-dimensional echocardiography, cardiac magnetic resonance, computed tomography and PET-computed tomography, are able to identify cardiovascular injury at different stages of arterial hypertension, from subclinical alterations and overt organ damage to possible complications related to pressure overload, thus giving a precious contribution for guiding timely and appropriate management and therapy, in order to improve diagnostic accuracy and prevent disease progression. The present review focuses on the peculiarity of different advanced imaging tools to provide information about different and multiple morphological and functional aspects involved in hypertensive cardiovascular injury. This evaluation emphasizes the usefulness of the emerging multiimaging approach for a comprehensive overview of arterial hypertension induced cardiovascular damage.

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.

Echocardiographic Advances in Dilated Cardiomyopathy

Although the overall survival of patients with dilated cardiomyopathy (DCM) has improved significantly in the last decades, a non-negligible proportion of DCM patients still shows an unfavorable prognosis. DCM patients not only need imaging techniques that are effective in diagnosis, but also suitable for long-term follow-up with frequent re-evaluations. The exponential growth of echocardiography’s technology and performance in recent years has resulted in improved diagnostic accuracy, stratification, management and follow-up of patients with DCM. This review summarizes some new developments in echocardiography and their promising applications in DCM. Although nowadays cardiac magnetic resonance (CMR) remains the gold standard technique in DCM, the echocardiographic advances and novelties proposed in the manuscript, if properly integrated into clinical practice, could bring echocardiography closer to CMR in terms of accuracy and may certify ultrasound as the technique of choice in the follow-up of DCM patients. The application in DCM patients of novel echocardiographic techniques represents an interesting emergent research area for scholars in the near future.

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.

Peguero-Lo Presti criteria for diagnosis of left ventricular hypertrophy: a cardiac magnetic resonance validation study

AIMS

The diagnostic performance of the new Peguero-Lo Presti ECG criteria for left ventricular hypertrophy (LVH) has not been validated by cardiac magnetic resonance (CMR). The aim of this study was to evaluate and compare the diagnostic performance of Peguero-Lo Presti, Cornell and Sokolow--Lyon voltage criteria for LVH as defined by CMR in an all-comers European population.

METHODS

A total of 240 consecutive patients referred for CMR who had a concomitant electrocardiogram for review were evaluated. LVH group patients were defined according to the reference values for sex and age of left ventricular mass index (LVMi). A control group, adjusted by sex, was randomly selected from a population without LVH. We applied the ECG voltage criteria to both groups and evaluated their diagnostic accuracy. Diagnostic sensitivity and specificity were compared.

RESULTS

Two hundred and forty patients (mean age 63 years; 65% men) were divided into two groups (LVH n = 149; control n = 91). The main causes of LVH were hypertension (24.8%) and hypertrophic cardiomyopathy (21.5%). The remaining patients of this group had a diagnosis of dilated cardiomyopathy (14.8%), valvular heart disease (7.4%) and infiltrative cardiomyopathy (2.0%). Overall, the sensitivity for LVH diagnosis of the Peguero-Lo Presti criteria outperformed both the Cornell (47 vs. 29%, P < 0.001) and Sokolow--Lyon voltage criteria (vs. 25%, P < 0.001). The specificities of all the criteria were above 94%, without significant differences between them.

CONCLUSION

In an all-comers European population with LVH defined by CMR, the criteria of Peguero-Lo Presti showed increased sensitivity for this diagnosis, when compared with the Sokolow--Lyon and Cornell voltage criteria. As such, they could become the preferred ECG diagnostic tool when evaluating patients at risk for LVH.

Association between insulin resistance and left ventricular hypertrophy in asymptomatic, Black, sub-Saharan African, hypertensive patients: a case-control study

Background

Conflicting information exists regarding the association between insulin resistance (IR) and left ventricular hypertrophy (LVH). We described the associations between obesity, fasting insulinemia, homeostasis model assessment of insulin resistance (HOMA-IR), and LVH in Black patients with essential hypertension.

Methods

A case–control study was conducted at the Centre Médical de Kinshasa (CMK), the Democratic Republic of the Congo, between January and December 2019. Cases and controls were hypertensive patients with and without LVH, respectively. The relationships between obesity indices, physical inactivity, glucose metabolism and lipid disorder parameters, and LVH were assessed using linear and logistic regression analyses in simple and univariate exploratory analyses, respectively. When differences were observed between LVH and independent variables, the effects of potential confounders were studied through the use of multiple linear regression and in conditional logistic regression in multivariate analyses. The coefficients of determination (R²), adjusted odds ratios (aORs), and their 95% confidence intervals (95% CIs) were calculated to determine associations between LVH and the independent variables.

Results

Eighty-eight LVH cases (52 men) were compared against 132 controls (81 men). Variation in left ventricular mass (LVM) could be predicted by the following variables: age (19%), duration of hypertension (31.3%), body mass index (BMI, 44.4%), waist circumference (WC, 42.5%), glycemia (20%), insulinemia (44.8%), and HOMA-IR (43.7%). Hypertension duration, BMI, insulinemia, and HOMA-IR explained 68.3% of LVM variability in the multiple linear regression analysis. In the logistic regression model, obesity increased the risk of LVH by threefold [aOR 2.8; 95% CI (1.06–7.4); p = 0.038], and IR increased the risk of LVH by eightfold [aOR 8.4; 95 (3.7–15.7); p < 0.001].

Conclusion

Obesity and IR appear to be the primary predictors of LVH in Black sub-Saharan African hypertensive patients. The comprehensive management of cardiovascular risk factors should be emphasized, with particular attention paid to obesity and IR. A prospective population-based study of Black sub-Saharan individuals that includes the use of serial imaging remains essential to better understand subclinical LV deterioration over time and to confirm the role played by IR in Black sub-Saharan individuals with hypertension.

Cardiac remodeling in middle-aged endurance athletes: relation between signal-averaged electrocardiogram and LV mass

The relationship between structural and electrical remodeling in the heart, particularly after long-standing endurance training, remains unclear. Signal-averaged electrocardiogram (SAECG) may provide a more sensitive method to evaluate cardiac remodeling than a 12-lead electrocardiogram (ECG). Accurate measures of electrical function (SAECG filtered QRS duration (fQRSd) and late potentials (LP) and left-ventricular (LV) mass (cardiac magnetic resonance, CMR) can allow an assessment of structural remodeling and QRS prolongation. Endurance athletes (45-65 yr old, >10 yr of endurance sport), screened to exclude cardiac disease, had standardized 12-lead ECG, SAECG, resting echocardiogram (ECHO), and CMR performed. SAECG fQRSd was correlated with QRS duration on the 12-lead ECG, and ECHO and CMR-derived LV mass. Participants (n = 82, 67% male, mean age: 54 ± 6 yr, mean V̇o_2max: 50 ± 7 mL/kg/min) had a CMR-derived LV mass of 118 ± 28 g/m² and a fQRSd of 112 ± 8 ms (46% had abnormal fQRSd (>114 ms), and 51% met clinical threshold for abnormal SAECG). fQRSd was positively correlated with the 12-lead ECG QRS duration (r = 0.83), ECHO-derived LV mass (r = 0.60), CMR-derived LV mass (r = 0.58) and LV end-diastolic volume (r = 0.63, P < 0.001 for all). fQRSd had higher correlations with ECHO and CMR-derived LV mass than 12-lead ECG (P < 0.0008 and P < 0.0005, respectively). In conclusion, in a healthy cohort of middle-aged endurance athletes, the SAECG is often abnormal by conventional criteria, and is correlated with structural remodeling, but CMR evaluation does not indicate pathologic structural remodeling. SAECG fQRSd is superior to the 12-lead ECG for the electrocardiographic evaluation of LV mass.NEW & NOTEWORTHY Study findings indicate that a positive correlation exists between electrical (SAECG fQRSd) and structural indices (LV mass) in middle-aged endurance athletes with normal physiological LV adaptation, in the absence of known cardiac pathology. SAECG fQRSd may also provide an alternative, superior method for identifying increased LV mass compared to other 12-lead ECG criteria.

Cardiac MRI demonstrates compressibility in healthy myocardium but not in myocardium with reduced ejection fraction

BACKGROUND

The professional guidelines assume that the myocardial volume in systole (MVs) is equal to that in diastole (MVd), despite some limited evidence that points to the contrary. The aim of this manuscript is to determine whether this is true in healthy myocardium using gold standard cardiac MRI, as well as transthoracic echocardiography (TTE). The secondary aim is to determine whether there are similar MV changes in patients with heart failure with reduced ejection fraction (HFrEF).

METHOD

A prospectively derived cohort at Mayo Clinic of 115 adult subjects (mean age 42.8 years, 58% female) with no cardiac risk factors was identified. Cardiac MRI was obtained on all 115 patients, 51 of whom also consented to a TTE. MRI from a retrospectively derived cohort of 50 HFrEF patients was also collected. MVs and MVd was calculated using standard approaches with inclusion of the papillary muscles.

RESULTS

In the healthy population, MRI demonstrated MVs/MVd = 0.87 (SD 0.04) and TTE demonstrated MVs/MVd = 0.79 (SD 0.07), suggesting compressibility (p < 0.0001). In the 51 healthy patients who received both imaging modalities, MVs/MVd was 8.0% higher in MRI than TTE (p < 0.0001), but both modalities had MVs/MVd < 1 (p < 0.0001). A Bland-Altman plot demonstrated that as the mean MVs/MVd increases, the difference in MVs/MVd MRI-TTE declines (r = -0.53, p < 0.0001). However, in HFrEF populations, MVs/MVd = 1.01 (0.03), suggesting myocardial incompressibility.

CONCLUSION

Contrary to currently accepted standards, healthy myocardium is compressible but HFrEF myocardium is incompressible. The ratio MVs/MVd merits further study in an expanded normal cohort and in disease states.

Impact of left ventricular mass/end-diastolic volume ratio by three-dimensional echocardiography on two-dimensional global longitudinal strain and diastolic function in native hypertensive patients

BACKGROUND

In hypertensive patients, high left ventricular (LV) mass/end-diastolic volume ratio (LVM/EDV) is related to LV dysfunction and myocardial fibrosis.

PURPOSE

We examined the ability of 3D-echo-derived LVM/EDV ratio in identifying early systolic and diastolic dysfunction in relation with LV concentric geometry in native hypertensive patients.

METHODS

One-hundred and forty-four newly diagnosed, never treated hypertensive patients underwent 2D-echo, including computation of 2D-derived global longitudinal strain (GLS), and 3D-echo. The study population was divided into two groups: elevated 3D-LVM/EDV (≥1.23 in women and ≥1.22 in men), corresponding to LV concentric geometry (n = 50), and normal ratio (<1.23 in women and <1.22 in men) corresponding to LV normal or eccentric geometry (n = 94).

RESULTS

The two groups were comparable for sex, heart rate, BMI, and blood pressure (BP). Patients with elevated 3D-LVM/EDV ratio were older and had lower GLS (P < 0.001) than patients with normal LVM/EDV ratio. Transmitral E/A ratio (P < 0.0001) and e' velocity (P < 0.0001) were lower, and E/e' ratio (P < 0.0001) higher in patients with elevated LVM/EDV ratio. In the pooled population, LVM/EDV ratio was positively correlated to E/e' (r = 0.39, P < 0.0001) and negatively to GLS (r = -0.29, P < 0.001). By separate multilinear regression analyses, after adjusting for sex, age, heart rate, mean BP and BMI, LVM/EDV ratio - but not 2D-relative wall thickness - was independently associated with E/e' (β = 0.304, P = 0.003) and GLS (β = -0.501, P < 0.0001).

CONCLUSION

Three-dimensional echocardiographic assessment of LV concentric geometry allows identifying an early diastolic and longitudinal systolic dysfunction in native hypertensive patients. In particular, 3D-LVM/EDV ratio is independently associated with both E/e' ratio and GLS.

Three-Dimensional Echocardiography - Role in Clinical Practice and Future Directions

Echocardiography has become an extension of the physical examination in cardiovascular practice. Frequently, it is used to confirm a clinical diagnostic suspicion. Another important role is to detect the underlying cardiovascular lesion to explain a patient's symptom complex or an abnormality found on chest radiography, electrocardiography, or cardiac enzyme tests. Patients are referred to the echocardiography laboratory because of their symptoms or due to non-specific laboratory abnormalities, and echocardiographers are expected to provide a definite diagnosis or a therapeutic clue. The introduction of the matrix array transducer into clinical practice allowed the acquisition of three-dimensional (3D) datasets. 3D echocardiography (3DE) has many advantages over 2-dimensional echocardiography, such as: (1) improved visualization of the complex shapes and spatial relations between cardiac structures; (2) improved quantification of the cardiac volumes and function; and (3) improved display and assessment of valve dysfunction. 3DE is increasingly utilized during routine clinical practice. This review article is aimed to examine the current clinical utility and future directions of 3DE.

Sex differences in aortic stenosis: from pathophysiology to treatment

Introduction: In aortic stenosis (AS), there are clear sex differences in clinical presentation, left ventricular (LV) response to pressure overload, and pathophysiology of valvular calcification. These differences may affect outcome following valve intervention.Area covered: This review aims to discuss sex differences in clinical presentation, pathophysiology of aortic valve calcification, LV remodeling in view of historic and recent echocardiographic and cardiac magnetic resonance imaging studies, and outcome after valve intervention. In addition, it will also provide some brief insights on the exercise physiology in women and men with AS.Expert commentary: Women at presentation are often older, have higher prevalence of hypertension and diastolic dysfunction, while men are younger, and more often have a bicuspid aortic valve and higher atherosclerotic disease burden. Men have more valve calcification than women for a given severity of AS and develop different patterns of LV remodeling and myocardial fibrosis. Although women tend to walk shorter on treadmill and achieve lower metabolic equivalents, they achieve similar peak heart rates and blood pressure, and the frequency of revealed symptoms during exercise test is comparable in both sexes. Men are more likely to undergo a surgical AVR with better outcome, while women have generally better outcome after TAVI.

Left Ventricular End Diastolic Volume and Ejection Fraction Calculation: Correlation between Three Echocardiographic Methods

Background

Left ventricular ejection fraction (LVEF) and end diastolic volume (EDV) are measured using Simpson's biplane (SB), 3-dimensional method (3DE), and speckle tracking (STE). Comparisons between methods in routine practice are limited. Our purpose was to compare and to determine the correlations between these three methods in clinical setting.

Methods

LVEF and EDV were measured by three methods in 474 consecutive patients and compared using multiple Bland–Altman (BA) plots. The correlations (R) between methods were calculated.

Results

Median (IQR) LVEF_SB, LVEF_STE, and LVEF_3DE were 63.0% (60–69)%, 61% (57–65)%, and 62% (57–68)%. Median (IQR) EDV_SB, EDV_STE, and EDV_3DE were 85 ml (71–106) ml, 82 ml (69–100) ml, and 73 ml (59–89) ml. R between LVEF_SB and LVEF_3DE was 0.65 when echogenicity was good and 0.43 when poor. R for EDV_SB and EDV_3DE was 0.75 when echogenicity was good and 0.45 when poor. On BA analysis, biases were acceptable (<3.5% for LVEF) but limits of agreement (LOA) were large: 95% of the differences were between −15.4% and +18.8% for LVEF as evaluated by SB in comparison with 3DE, with a bias of 1.7%. In the comparison EDV_SB and EDV_3DE, the bias was 14 ml and the LOA were between −24 ml and +53 ml. On linear regressions, LVEF_3DE = 17.92 + 0.69 LVEF_SB and EDV_3DE = 18.94 + 0.63 EDV_SB.

Conclusions

The three methods were feasible and led to acceptable bias but large LOA. Although these methods are not interchangeable, our results allow 3DE value prediction from SB, the most commonly used method.

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.

Proof-of-concept for a non-invasive, portable, and wireless device for cardiovascular monitoring in pediatric patients

Measurement of cardiac function is vital for the health of pediatric patients with heart disease. Standard tools to measure function including echocardiogram and magnetic residence imaging are time intensive, costly, and have limited accessibility. The Vivio is a novel, non-invasive, handheld device that screens for cardiac dysfunction by analyzing intrinsic frequencies (IF) ω₁ and ω₂ of carotid artery waveforms. Prior studies demonstrated that left ventricular ejection fraction can be derived from IFs in adults. This study 1) studies whether the Vivio can capture carotid arterial pulse waveform data in children ages 0–19 years old; 2) tests the performance of two sensor head geometries, one larger and smaller than the standard size used in adults, designed for the pediatric population; 3) compares the IFs between pediatric age groups and adults with normal function. The Vivio successfully measured a carotid artery waveform in all children over 5 years old and 28% of children under the age of five. The small head did not accurately measure a waveform in any age group. One-way analysis of variance (ANOVA) demonstrated a difference in the IF ω₁ between the adult and pediatric cohorts (F = 7.3, Prob>F = 0.0001). Post host analysis demonstrated a difference between the adult cohort (ω₁ = 99 +/- 5 bpm) and the cohorts ages 0–4 (ω₁ = 111 +/- 2 bpm; p = 0.0006) and 15–19 years old (ω₁ = 105 +/-5 bpm; p = 0.02). One-way ANOVA demonstrated a difference in the IF ω₂ between the adult and pediatric cohorts (F = 4.8, Prob>F = 0.003), specifically between the adult (ω₂ = 81 +/- 13 bpm) and age 0–4 cohorts (ω₂ = 48 +/- 8 bpm; p = 0.002). These results suggest that the Vivio can be used to capture carotid pulse waveform data in pediatric populations and that the data produced can be used to measure intrinsic frequencies.

Echocardiographic Left Ventricular Mass Estimation: Two-Dimensional Area-Length Method is Superior to M-Mode Linear Method in Swine Models of Cardiac Diseases

Echocardiography offers rapid and cost-effective estimations of left ventricular (LV) mass, but its accuracy in patients with cardiac disease remains unclear. LV mass was measured by M-mode-based linear method and two-dimensional echocardiography (2DE)-based area-length method in pig models and correlation with actual LV weight was assessed. Twenty-six normal, 195 ischemic heart disease (IHD), and 33 non-IHD HF pigs were included. A strong positive linear relationship to the actual LV weight was found with 2DE-based area-length method (r = 0.82, p < 0.001), whereas a moderate relationship was found with M-mode method in the overall population (r = 0.68, p < 0.001). Two correlation coefficients were significantly different (p < 0.001), and were driven mainly by incremental overestimation of LV mass in heavier hearts using the M-mode method. IHD and LV dilation were the factors contributing to overestimation using M-mode method. 2DE-based area-length method provides a better estimation of LV weight in swine models of HF, particularly in those with IHD.

Myocardial Oxygen Consumption and Efficiency in Patients With Cardiac Amyloidosis

Background

This study evaluated myocardial oxygen consumption (MVO₂) and myocardial external efficiency (MEE) in patients with cardiac amyloidosis (CA). Furthermore, we compared MEE and MVO₂ in subjects with light chain amyloidosis versus transthyretin (ATTR) amyloidosis.

Methods and Results

The study population comprised 40 subjects: 25 patients with confirmed CA and 15 control subjects. All subjects underwent an ¹¹C‐acetate positron emission tomography. Furthermore, the CA patients underwent comprehensive echocardiography and right heart catheterization during a symptom‐limited, semi‐supine exercise test. MEE was calculated from ¹¹C‐acetate positron emission tomography as the ratio of left ventricular (LV) stroke work and the energy equivalent of MVO₂. Myocardial work efficiency was calculated as echocardiography‐derived work pressure product divided by three‐dimensional LV mass. CA patients had significantly lower LV‐ejection fraction (54±13% versus 63±4%, P<0.05) and LV‐global longitudinal strain (LVGLS) (12±4% versus 19±2%, P<0.0001) and a more restrictive filling pattern (E/e′‐ratio 18 [12–25] versus 8 [7–9], P<0.0001) than controls. MEE was severely reduced (13±5% versus 22±5%, P<0.0001) whereas total MVO₂ was higher (18±6 mL/min versus 13±3 mL/min, P<0.01) in CA patients than controls. MEE decreased with increasing New York Heart Association symptom burden (P<0.0001). We found a good relationship between MEE and peak exercise systolic performance (LVGLS: R²=0.60, P<0.0001; myocardial work efficiency: R²=0.48, P<0.0001; cardiac index: R²=0.52, P<0.0001) and between MEE and myocardial blood flow (R²=0.44, P<0.0001).

Conclusion

Myocardial oxidative metabolism is disturbed in CA patients with increased total MVO₂ and reduced MEE. MEE correlated significantly with echocardiographic derived systolic parameters such as myocardial work efficiency and LVGLS that might be used as surrogate MEE markers.

Performance of a new fully automated transthoracic three-dimensional echocardiographic software for quantification of left cardiac chamber size and function: Comparison with 3 Tesla cardiac magnetic resonance

PURPOSE

To evaluate the accuracy and reproducibility of a new fully automated fast three-dimensional (3D) transthoracic echocardiography (TTE) software for the simultaneous assessment of left atrial (LA) volumes and LA ejection fraction (EF), left ventricular (LV) volumes, LV mass, and LVEF, and to compare the results obtained with a cardiac magnetic resonance (CMR) reference.

METHODS

We included retrospectively 56 patients (46 men; mean age 63 ± 13 years) in sinus rhythm who had had comprehensive 3D TTE and CMR examinations within 24 hours.

RESULTS

Despite a slight underestimation of LV and LA volumes, LVEF and LAEF were similar using CMR or 3DTTE (58% ± 16% vs 58% ± 12%; P = .65 and 45% ± 14% vs 46% ± 15%; P = .38, respectively) in the total population. Despite significant correlation between TTE and CMR measurements (r = 0.78; P < .001), 3D TTE underestimated LV mass (bias = -27 ± 35 g).

CONCLUSION

3D TTE using a new-generation fully automated software is a fast and reproducible imaging modality for simultaneous extensive quantification of left heart chambers size and function in routine practice. Potential underestimation of LA volume and LV mass, and of LVEF in patients with LVEF <50%, should be taken into consideration.

Left ventricular mass estimation by real-time 3D echocardiography favourably competes with CMR in congenital left ventricular disease

Assessment of left ventricular mass (LVM) is important in the evaluation of patients with congenital heart disease (CHD) and cardiac magnetic resonance imaging (CMR) is the gold standard. Recent software allows LVM calculation by real-time 3-dimensional echocardiography (RT3DE). We investigated the impact of different software analysis tools on LVM determination by CMR or RT3DE in a cohort of patients with heterogeneous left ventricular (LV) disease. 37 subjects (17 patients, mean age 18.7 y; 20 controls, mean age 13.2 y) underwent CMR and RT3DE. CMR LVM and RT3DE calculations were done using two different LV-analysis software packages for each modality: CMR i) customized software “CMR HDZ”, CMR ii) “CMR ISP”; RT3DE i) “Toshiba”, RT3DE ii) “Tomtec”, 4D LV-Analysis Version 3.1 (built 3.1.0.258661). Intra- and interobserver variabilities were calculated. Only RT3DE-derived LVM showed significant software-dependent differences. RT3DE-derived LVM (both softwares) was significantly higher than CMR-derived LVM (both softwares). The two different methods and four evaluation software packages for LVM assessment were well correlated with each other. Intra- and interobserver variability of LVM as assessed by each single modality or software was low. Despite software dependency and overestimation of RT3DE-assessed LVM by 5 to 10%, RT3DE still competes with the gold standard, CMR, even in patients with various forms of LV disease. The use of optimized software, especially for RT3DE, should improve the accuracy of LVM assessment, overcoming LVM overestimation.

Three-dimensional echocardiographic ventricular mass/end-diastolic volume ratio in native hypertensive patients: relation between stroke volume and geometry

BACKGROUND

Elevated left ventricular (LV) mass/end-diastolic volume ratio (LVM/EDV) has been associated with higher evidence of myocardial fibrosis and dysfunction in hypertensive patients by cardiac magnetic resonance, a technique with limited availability.

OBJECTIVES

We investigated the ability of three-dimensional (3D) echocardiography in identifying a phenotype of LV concentric geometry according to LVM/EDV ratio, possibly detecting early myocardial damage in native-hypertensive patients.

METHODS

One hundred and twenty-eight native-hypertensive patients underwent 2D and 3D-echocardiography. The population was divided into two groups, according to cut-off point values of 3D-LVM/EDV ratio corresponding to its upper 95% confidence interval in a population of 90 healthy normotensive individuals: LVM/EDV ratio cut-off was 1.22 in men and 1.23 in women.

RESULTS

An increased 3D-LVM/EDV ratio identified a higher rate of LV concentric geometry in comparison with 2D-derived relative wall thickness (37 versus 24%, P = 0.03). Patients with LVM/EDV ratio of 1.22 or more in men and 1.23 or more in women were significantly older, had smaller 3D-LV end-diastolic and end-systolic volumes and higher LV mass index, without difference in ejection fraction. 3D-stroke volume (P < 0.0001) was lower in patients with elevated LVM/EDV ratio. By a multilinear regression analysis, after adjusting for sex, age, heart rate, mean blood pressure and BMI, stroke volume was independently and negatively associated to LVM/EDV ratio (β = -0.55, P < 0.0001).

CONCLUSION

In native hypertensive patients, 3D-echo-derived LVM/EDV ratio identifies a higher prevalence of LV concentric geometry than 2D-relative wall thickness. Stroke volume is independently and negatively associated with LVM/EDV ratio and its reduction represents an early marker of myocardial dysfunction in hypertensives with LV concentric geometry.

Left Ventricular Mass and Thickness: Why Does It Matter?

Several left ventricular geometric patterns have been described both in healthy and pathologic hearts. Left ventricular mass, wall thickness, and the ratio of wall thickness to radius are important measures to characterize the spectrum of left ventricular geometry. For clinicians, an increase in left ventricular mass is the hallmark of left ventricular hypertrophy. Although pathologic hypertrophy initially can be compensatory, eventually it may become maladaptive and evolve toward progressive left ventricular dysfunction and heart failure. In particular, patients who show left ventricular dilation and hypertrophy in association with a low relative wall thickness are likely to carry the highest risk.

Diagnostic performance of electrocardiographic criteria for left ventricular hypertrophy among various body mass index groups compared to diagnosis by cardiac magnetic resonance imaging

BACKGROUND

Presence of left ventricular hypertrophy (LVH) increases the risk for cardiovascular event. Many electrocardiographic (ECG) criteria can be used to diagnose LVH; however, high body mass index (BMI) may reduce ECG amplitudes.The aim of this study was to investigate the diagnostic performance of ECG criteria for diagnosing LVH among various BMI groups compared to diagnosis by cardiac magnetic resonance (CMR) imaging.

METHODS

Patients who were referred for CMR were enrolled. CMR and ECG were performed on the same day. Left ventricular function, volume, and mass were calculated from CMR. Standard ECG criteria were measured, including: Cornell voltage, Cornell product, Romhilt-Estes point score system, Sokolow-Lyon index, and Sokolow-Lyon-Rappaport index. Diagnostic performance of each ECG criterion was calculated and analyzed in the following four BMI groups: underweight (<18.5 kg/m² ), normal (18.5-22.9 kg/m² ), overweight (23-24.9 kg/m² ), and obese (≥25 kg/m² ).

RESULTS

Of the 1,882 patients that were included, 67 were underweight, 459 were normal weight, 434 were overweight, and 922 were obese. LVH was diagnosed in 34 (50.7%) underweight, 144 (31.4%) normal weight, 100 (23.0%) overweight, and 181 (19.6%) obese patients. Overall specificity of ECG was high (0.89-0.95), and overall sensitivity was low (0.25-0.37). The specificity of each ECG criterion was similar among BMI groups; however, the sensitivity of ECG criteria demonstrated a decreasing trend in the higher BMI groups.

CONCLUSION

All ECG criteria demonstrated relatively high specificity and relatively low sensitivity. Although the specificity across groups remained similar, higher BMI was found to be associated with decreased sensitivity.

Automated, machine learning-based, 3D echocardiographic quantification of left ventricular mass

BACKGROUND

Although 3D echocardiography (3DE) circumvents many limitations of 2D echocardiography by allowing direct measurements of left ventricular (LV) mass, it is seldom used in clinical practice due to time-consuming analysis. A recently developed 3DE machine learning (ML) approach allows automated determination of LV mass. We aimed to evaluate the accuracy of this new approach by comparing it to cardiac magnetic resonance (CMR) reference and to conventional 3DE volumetric analysis.

METHODS

We prospectively studied 23 patients who underwent 3DE (Philips EPIQ) and CMR imaging on the same day. Single-beat wide-angle 3D datasets of the left ventricle were acquired. LV mass was quantified using the new automated software (Philips HeartModel) with manual corrections when necessary and using conventional volumetric analysis (TomTec). CMR analysis was performed by manual slice-by-slice tracing of LV endo- and epicardial boundaries. Reproducibility of the ML approach was assessed using repeated measurements and quantified by intra-class correlation (ICC) and coefficients of variation (CoV).

RESULTS

Automated LV mass measurements were feasible in 20 patients (87%). The results were similar to CMR-derived values (Bland-Altman bias 5 g, limits of agreement ±37 g) and also to the conventional 3DE analysis (bias 7 g, ±27 g). Processing time was considerably shorter: 1.02 ± 0.24 minutes (CMR: 2.20 ± 0.13 minutes; TomTec: 2.36 ± 0.09 minutes), although manual corrections were performed in most patients. Repeated measurements showed high reproducibility: ICC = 0.99; CoV = 4 ± 5%.

CONCLUSIONS

3D Echocardiography analysis of LV mass using novel ML-based algorithm is feasible, fast, and accurate and may thus facilitate the incorporation of 3DE measurements of LV mass into clinical practice.

Quantitative assessment of two- and three-dimensional transthoracic and two-dimensional transesophageal echocardiography, computed tomography, and magnetic resonance imaging in normal canine hearts

INTRODUCTION

The objective of the study was to evaluate the accuracy of two- and three-dimensional (2D, 3D) transthoracic echocardiography (TTE), 2D transesophageal echocardiography, and computed tomography angiography (CTA) compared with cardiac magnetic resonance imaging (CMR) in normal dogs and to assess repeatability of 2D and 3D TTE for the assessment of left ventricular (LV) and left atrial (LA) dimensions.

ANIMALS

The study was performed on six healthy dogs.

MATERIALS AND METHODS

Transthoracic echocardiography, transesophageal echocardiography, CTA, and CMR were performed on each dog. Right ventricular (RV) and LV volumes (in systole and diastole), ejection fraction (EF), and LA and right atrial (RA) volumes were assessed. Repeatability and intrarater and interrater measurements of variability were quantified by average coefficient of variation (CV) for 2D and 3D TTE.

RESULTS

No clinically relevant differences in LV volume were detected between CMR and all modalities. Importantly, 3D TTE had the lowest CV (6.45%), correlated with (r_s = 0.62, p = 0.01), and had the highest overlap in distribution with CMR (OVL >80%). Left ventricular EF and LA size via CTA compared best with CMR and RV and RA volumes were best estimated by 3D TTE. Assessment of LV and LA volumes via 3D TTE had moderate repeatability (15-21%) compared with LV M-mode measurements and 2D LA-to-aortic ratio (<10%), respectively. For LV size, interrater CV for 3D TTE (19.4%) was lower than 2D TTE (23.1%).

CONCLUSIONS

Measurements of LV, RV, and RA volumes via 3D TTE and LA volume and LV EF assessed by CTA compared best with CMR. Three-dimensional echocardiography had lower interrater and intrarater CV compared with 2D TTE.

Real-time three-dimensional echocardiographic left heart parameters in healthy indian adults

OBJECTIVE

Cardiac chamber dimensions are race and anthropometry dependent. We determined the age and gender specific 3-Dimensional echocardiographic (3DE) reference values for dimensions and function of left ventricle (LV) and left atrium (LA) in normal Indian adults.

METHODS

This single center prospective study enrolled 133 adult Indians free of heart disease and/or hypertensions, subjecting them to 3DE measurements of left atrial (LA) & left ventricular (LV) volumes, function and left ventricular mass (LVM). The higher limits of normal cut-offs were determined for these parameters and their dependency on age, gender and anthropometry were analyzed.

RESULTS

The body surface area (BSA) corrected higher limit cut-offs were: 59.37ml/m2 for LV end diastolic volume (59.19ml/m2 and 59.61ml/m2 for men and women, respectively; P=NS); 23.48ml/m2 for LV end systolic volume (23.27ml/m2 and 23.11ml/m2 for men and women, P=NS). Mean LVEF was 64.79%±7.26 (62.99%±6.51 and 67.05%±7.58 in men and women, P=NS). Men had higher LVM than women (119.79g±23.95 vs. 103.26g±23.76, P<0.001), this difference disappeared after BSA indexing. The higher limit cut-offs for normal LA volumes were 20.49ml for minimum volume (21.18ml and 19.46ml for men and women, P=NS) and 39.76ml for maximum volume (39.60ml and 40.03ml in men and women, P=NS). The parameters were smaller compared to western populations but the differences attenuated after BSA indexing.

CONCLUSIONS

The study reports normal 3DE parameters of size and function of left heart chambers in Indians.

Comparison of Cardiac Magnetic Resonance Imaging and Echocardiography in Assessment of Left Ventricular Hypertrophy in Fabry Disease

BACKGROUND

Cardiac hypertrophy in Fabry disease can be assessed using the left ventricular mass index (LVMI) with either echocardiography (LVMI-ECHO) or magnetic resonance imaging (LVMI-CMR).

METHODS

A retrospective case series of patients with Fabry disease in Alberta involved a cross-sectional analysis of 32 patients and a longitudinal analysis of 14 of these patients with at least 4 serial CMR measurements.

RESULTS

The cross-sectional analysis showed the mean LVMI-ECHO was 97.8 ± 26.0 g/m², which was higher compared with LVMI-CMR at 81.1 ± 26.9 g/m² with a mean bias of 16.7 g/m² (P < 0.001). In the longitudinal analysis, LVMI-ECHO was higher, with an estimated marginal mean of 96.21 ± 6.13 (mean ± standard error of the mean [SEM]) compared with 71.18 ± 5.99 for LVMI-CMR (P < 0.01; generalized estimating equations). There was an association between an increase in LVMI-CMR over time with the presence of cardiac fibrosis, and patients treated with enzyme replacement therapy (ERT) had slower increases than those without therapy. LVMI-ECHO failed to detect these associations owing to the higher variability and tendency to overestimate the LVMI.

CONCLUSIONS

We propose the preferred method for measuring LVMI is CMR in patients with Fabry disease.

Abnormal Coronary Flow Velocity Reserve and Decreased Myocardial Contractile Reserve Are Main Factors in Relation to Physical Exercise Capacity in Cardiac Amyloidosis

BACKGROUND

The aim of the present study was to evaluate the clinical importance of echocardiographic coronary flow velocity reserve (CFVR), resting and exercise left ventricular global longitudinal strain (LVGLS), and myocardial work efficiency (MWE) in patients with cardiac amyloidosis (CA).

METHODS

The study population comprised 69 subjects: group A, 27 patients with CA confirmed by endomyocardial biopsy (CA positive); group B, 42 healthy control subjects. The amyloid phenotype in group A was as follows: patients with wild-type transthyretin-related amyloidosis (n = 10), carriers of the Danish familial transthyretin amyloidosis mutation with cardiac involvement (n = 5), and patients with amyloid light chain amyloidosis with cardiac involvement (n = 12). All subjects underwent comprehensive echocardiographic evaluation during rest and during symptom-limited, semisupine exercise testing. Furthermore, CFVR was assessed using Doppler echocardiography.

RESULTS

Patients with CA had significantly lower CFVR (1.7 ± 0.6 vs 3.9 ± 0.8, P < .0001), MWE (1.9 ± 1.0 vs 3.0 ± 0.7, P < .0001), and LVGLS magnitude (11% [10%-14%] vs 20% [18%-21%], P < .0001) than control subjects. Patients with CA showed severely reduced deformation and efficiency reserve compared with control subjects (ΔLVGLS 0.9 ± 2.8% vs 5.6 ± 2.3%, P < .0001; ΔMWE 2.5 ± 2.8 vs 8.8 ± 2.6, P < .0001). In patients with CA, a strong relation was seen between physical capacity by the metabolic equivalent of tasks test and CFVR (r = 0.55, P < .01), peak exercise LVGLS (r = 0.64, P < .0001), and peak exercise MWE (r = 0.60, P < .01).

CONCLUSIONS

Patients with CA had a profound lack of CFVR and longitudinal myocardial deformation reserve compared with healthy control subjects. Both parameters were significantly associated with exercise capacity and may prove useful for evaluating cardiac performance in patients with CA.

A 3D Hermite-based multiscale local active contour method with elliptical shape constraints for segmentation of cardiac MR and CT volumes

Analysis of cardiac images is a fundamental task to diagnose heart problems. Left ventricle (LV) is one of the most important heart structures used for cardiac evaluation. In this work, we propose a novel 3D hierarchical multiscale segmentation method based on a local active contour (AC) model and the Hermite transform (HT) for LV analysis in cardiac magnetic resonance (MR) and computed tomography (CT) volumes in short axis view. Features such as directional edges, texture, and intensities are analyzed using the multiscale HT space. A local AC model is configured using the HT coefficients and geometrical constraints. The endocardial and epicardial boundaries are used for evaluation. Segmentation of the endocardium is controlled using elliptical shape constraints. The final endocardial shape is used to define the geometrical constraints for segmentation of the epicardium. We follow the assumption that epicardial and endocardial shapes are similar in volumes with short axis view. An initialization scheme based on a fuzzy C-means algorithm and mathematical morphology was designed. The algorithm performance was evaluated using cardiac MR and CT volumes in short axis view demonstrating the feasibility of the proposed method.

Inotropic myocardial reserve deficiency is the predominant feature of exercise haemodynamics in cardiac amyloidosis

AIMS

This study aimed to characterize invasive haemodynamics during exercise in subjects with cardiac amyloidosis (CA).

METHODS AND RESULTS

The study population numbered 44 subjects. Group A (CA-positive, n = 24) comprised wild-type transthyretin patients (n = 10), familial transthyretin amyloidosis mutation carriers (ATTRm) with cardiac involvement (n = 5), and light-chain amyloidosis patients with cardiac involvement (n = 9). Group B (CA-negative, n = 20) comprised four healthy ATTRm subjects without cardiac involvement documented by ¹¹ C-PIB positron emission tomography and 16 healthy controls. All subjects underwent a symptom-limited, semi-supine exercise test with expired gas analysis and simultaneous right heart catheterization. CA patients had lower peak oxygen consumption [15 ± 6 mL/min/kg bodyweight (bwt) vs. 33 ± 7 mL/min/kg bwt; P < 0.0001] than controls. Myocardial reserve during exercise was significantly reduced in CA patients as reflected in a small increase in stroke volume index (SVI) and cardiac index (CI) compared with controls [ΔSVI: 4 mL/m² (range: -1 to 8) vs. 14 mL/m² (range: 5-25); P < 0.0001; ΔCI: 2 ± 2 L/min vs. 7 ± 2 L/min; P < 0.0001]. During exercise, CA patients had significantly higher left and right ventricular filling pressures than controls. Furthermore, CA patients had severely impaired pulmonary arterial compliance (PAC) compared with controls [2.9 mL/mmHg (range: 2.1-4.5) vs. 7.5 mL/mmHg (range: 5.7-10.4); P < 0.0001].

CONCLUSIONS

Cardiac amyloid deposits are associated with severely reduced inotropic myocardial reserve and increased left and right ventricular filling pressures during exercise. Furthermore, CA subjects have severely reduced PAC, which may contribute to right heart failure and reduced exercise capacity.

Cardiac Imaging in Heart Failure with Comorbidities

Imaging modalities stand at the frontiers for progress in congestive heart failure (CHF) screening, risk stratification and monitoring. Advancements in echocardiography (ECHO) and Magnetic Resonance Imaging (MRI) have allowed for improved tissue characterizations, cardiac motion analysis, and cardiac performance analysis under stress. Common cardiac comorbidities such as hypertension, metabolic syndromes and chronic renal failure contribute to cardiac remodeling, sharing similar pathophysiological mechanisms starting with interstitial changes, structural changes and finally clinical CHF. These imaging techniques can potentially detect changes earlier. Such information could have clinical benefits for screening, planning preventive therapies and risk stratifying patients. Imaging reports have often focused on traditional measures without factoring these novel parameters. This review is aimed at providing a synopsis on how we can use this information to assess and monitor improvements for CHF with comorbidities.

Usefulness of the maximum rate of pressure rise in the central and peripheral arteries after weaning from cardiopulmonary bypass in pediatric congenital heart surgery: A retrospective analysis

The maximum rate of pressure rise (dP/dtmax) in radial artery has been proposed as a noninvasive surrogate of aortic dp/dtmax, reflecting left ventricular (LV) contractility in children. The aim of this study was to investigate relationship between aortic and radial dp/dtmax at weaning from cardiopulmonary bypass (CPB) and usefulness of these indices for estimating postoperative outcomes in pediatric congenital heart surgery.Aortic and radial arterial pressure waveforms were analyzed simultaneously during weaning from CPB in 29 congenital heart surgery. The maximum first derivatives of aortic and radial arterial waveforms were calculated and averaged from 3 consecutive respiratory cycles. We obtained the maximum vasoactive inotropic score during the first 36 postoperative hours, LV ejection fraction, and fractional shortening on transthoracic echocardiography performed within postoperative day 7.A significant difference between aortic and radial dP/dtmax was observed (mean difference 356 mm Hg/s, 44% of averages), and radial dP/dtmax was weakly correlated with aortic dP/dtmax (r =0.373, P = 0.047). Aortic dP/dtmax was significantly associated with the maximum vasoactive inotropic score (P < 0.001), postoperative LV ejection fraction (P = 0.018), and fractional shortening (P = 0.015); however, radial dP/dtmax was not. On Receiver operating characteristic analysis, aortic dP/dtmax had a greater area under the curve than radial dP/dtmax in predicting higher vasoactive inotropic score (0.827 vs 0.673).Immediately after CPB in pediatric congenital heart surgery, radial dP/dtmax may not replace aortic dP/dtmax because of a discrepancy between central and peripheral arterial waveforms. In this critical period, aortic dP/dtmax can be useful to estimate postoperative ventricular function rather than peripherally derived dP/dtmax.

Assessment of the accuracy of common clinical thresholds for cardiac morphology and function by transthoracic echocardiography

BACKGROUND

We evaluated the ability of transthoracic echocardiography (TTE) to correctly identify abnormal left ventricular (LV) size, function, and mass when compared to cardiac magnetic resonance (CMR). Whilst numerous studies have compared TTE and CMR with respect to correlation between measurements and study reproducibility, few have employed categorical analysis relevant to clinical practice.

METHODS

Two hundred and fifteen consecutive patients who underwent both TTE and CMR were evaluated for the presence of abnormal LV size, systolic function, and mass. Abnormal LV systolic function was further categorized into grades (mild, moderate, and severe). Quantification of LV morphology and function was performed on TTE and CMR according to published guidelines. The level of agreement between TTE and CMR was compared across binary and categorical variables using Cohen's kappa.

RESULTS

Compared to CMR, TTE demonstrated excellent agreement in identification of abnormal versus normal function (κ = 0.87). However, agreement across grades of LV function was less strong (κ = 0.63). Whilst agreement for identification of severe LV dysfunction was good (κ = 0.68), this would still lead to misclassification of severe dysfunction in approximately one in seven cases. Agreement between TTE and CMR was moderate to good for identification of LV dilation (κ = 0.43-0.63), but poor for identification of increased mass (κ = 0.04).

CONCLUSIONS

Whilst in clinical practice TTE performs well in identification of normal versus abnormal systolic function, it has substantial limitations across grades of dysfunction and in the assessment of LV size and mass. These limitations have important implications when considering management decisions for patients based on thresholds of LV morphology or function.

Three-dimensional echocardiography in various types of heart disease: a comparison study of magnetic resonance imaging and 64-slice computed tomography in a real-world population

BACKGROUND

Accurate quantification of left ventricular (LV) volumes [end-diastolic volume (EDV) and end-systolic volume (ESV)] and ejection fraction (EF) is of critical importance. The development of real-time three-dimensional echocardiography (RT3DE) has shown better correlation than two-dimensional (2D) echocardiography with magnetic resonance imaging (MRI) measurements. The aim of our study was to assess the accuracy of RT3DE and 64-slice computed tomography (CT) in the evaluation of LV volumes and function using MRI as the reference standard in a real-world population with various types of heart disease with different chamber geometry.

METHODS

The study population consisted of 66 patients referred for cardiac MRI for various pathologies. All patients underwent cardiac MRI, and RT3DE and 64 slices CT were then performed on a subsequent day. The study population was then divided into 5 clinical groups depending on the underlying heart disease.

RESULTS

RT3DE volumes correlated well with MRI values (R ² values: 0.90 for EDV and 0.94 for ESV). RT3DE measurements of EF correlated well with MRI values (R ² = 0.86). RT3DE measurements resulted in slightly underestimated values of both EDV and ESV, as reflected by biases of -9.18 and -4.50 mL, respectively. Comparison of RT3DE and MRI in various types of cardiomyopathies showed no statistical difference between different LV geometrical patterns.

CONCLUSION

These results confirm that RT3DE has good accuracy in everyday clinical practice and can be of clinical utility in all types of cardiomyopathy independently of LV geometric pattern, LV diameter or wall thickness, taking into account a slight underestimation of LV volumes and EF compared to MRI.