A Multimodular AI Algorithm for Automated Assessment of Left Ventricular Function in Ischemic Heart Disease: Ejection Fraction, Wall Motion, and Regional Myocardial Segmentation.

A 20-year-old male presented to our department with complaints of dyspnea on effort for six months. On clinical examination, he had a low volume slow rising pulse, blood pressure of 100/70 mmHg and a raised jugular venous pressure. Cardiovascular examination revealed a downward and outward shifted apical impulse with an ejection systolic murmur of grade IV/VI intensity heard best at the right second intercostal space radiating to both carotids. There were bilateral basilar fine crepitations in chest. Two dimensional transthoracic echocardiography (2D TTE) with color Doppler (Fig. 1, Supplementary movie 1, 2, and 3) showed dilatation of all four cardiac chambers, left ventricle (LV) ejection fraction of 25% and multiple large layered as well as non-layered thrombi in the LV cavity. Aortic valve (AV) was bicuspid with severe aortic stenosis having a peak velocity of 4.2 m/sec. Three dimensional transthoracic echocardiography (3D TTE) clearly showed various details of the multiple thrombi like size, shape, mobility, number, location as well as the internal echolucent areas within the thrombus suggestive of clot lysis (Fig. 2, Supplementary movie 4). Patient denied any form of surgical intervention and was started on oral anticoagulation with warfarin (target INR: 2.0-3.0) along with standard decongestive therapy. A review echocardiography after 8 weeks (Fig. 3) showed complete disappearance of the LV thrombi. LV ejection fraction was almost unchanged. Fig. 1 Two dimensional transthoracic echocardiography with color Doppler. Multiple large layered as well as non-layered thrombi in LV marked by * are seen in slightly tilted parasternal long axis view (A) and in short axis view at the papillary muscle level ... Fig. 2 Real time three dimensional transthoracic echocardiography with volume rendering. The size, shape, number, mobility, surface characteristics, intracardiac location of thrombi can be clearly delineated in various imaging planes (A and B). Echolucency within ... Fig. 3 Two dimensional transthoracic echocardiography after 8 weeks of anticoagulation therapy. The multiple thrombi in the LV cavity have completely disappeared as seen in apical four chamber (A), parasternal long (B), and short axis (C) views. The LV ejection ... Congenital bicuspid AV is present in about 1-2% of the population and is more common in males.1) Most bicuspid AV function normally until late in life, although a subset of patients present in childhood or adolescence. Severe aortic stenosis can occur due to the bicuspid AV and if not treated in time can lead to LV dilatation with poor ejection fraction, which in turn can lead to pulmonary hypertension and right ventricular dilatation and dysfunction. In patients with dilated cardiomyopathy, the reported LV thrombus is 10-30%.2) Non-invasive assessment with 2D TTE plays a pivotal role in diagnosis of bicuspid AV with aortic stenosis and LV dysfunction.3) There is a clear advantage of 3D TTE over 2D TTE in the assessment of intra-cardiac masses. Once the images have been acquired, cropping of the data sets can provide a unique view of the interior composition of the mass which can reveal information about its nature. Since the clot lysis begins from inside to outside, 3D TTE reveals this important information by demonstrating areas of echolucency within the clot.4)

To compare global Left Ventricular (LV) systolic function assessment by 16-detector row Computed Tomography (MDCT) with Two-Dimensional Standard Echocardiography (2DSE) in a routine cardiology practice setting and to ascertain the degree of correlation between LV volumes and measurements obtained by 2DSE with those measured by MDCT. In 52 patients with suspected coronary artery disease, a contrast enhanced MDCT study was performed using retrospective gating without dose modulation for better endocardial delineation. Eight phases of the cardiac cycle were analyzed to identify the end-diastolic and end-systolic phases. 2DSE was performed on the same day. Left ventricular systolic and diastolic volumes and ejection fraction were calculated in 4-chamber, 2-chamber and biplane (average of the two) views. Endocardial tracing was used to measure ventricular volumes by area length method for CT and Simpson's method for echocardiography. On MDCT, mean LV ejection fraction (LVEF) in 4-chamber, 2-chamber and biplane views were 58.4 +/- 12, 59.3 +/- 12 and 59.7 +/- 12% respectively. On 2DSE, mean LVEF in 4-chamber, 2-chamber and biplane views were 58 +/- 14, 57 +/- 16 and 58 +/- 13% respectively. LVEF correlated best using the biplane views (r = 0.59 and P < 0.01) compared to 2-chamber (r = 0.57 and P < 0.01) and 4-chamber views (r = 0.32 and P = 0.02). Biplane measurement by these two techniques correlated well for LV volumes in both diastole (r = 0.69 and P < 0.01) and systole (r = 0.73 and P < 0.01), although MDCT consistently gave higher values. MDCT can be a useful tool to measure LVEF while patients are undergoing CT coronary angiography.

Three-Dimensional Speckle Tracking Echocardiography for Automatic Assessment of Global and Regional Left Ventricular Function Based on Area Strain

To evaluate the use of retrospectively ECG-gated, contrast-enhanced, multi-detector row computed tomography (MDCT) for assessment of left ventricular function in dogs and to compare the results with those obtained by use of 2-D and M-mode echocardiographc techniques. 10 healthy Beagles. Dogs underwent MDCT (performed by use of a 64-detector row CT system) and echocardiography under general anesthesia. Left ventricular end-systolic volume (ESV), end-diastolic volume (EDV), and ejection fraction (EF) were determined in MDCT-generated multiplanar reformatted images by use of Simpson and biplane area-length calculation methods. Results were compared with left ventricular ESV, EDV, and EF determined in echocardiographc images by use of Teichholz and bullet method calculations. Results were evaluated via Deming regression analysis and Pearson correlation tests. Bland-Altman analysis was used to assess limits of agreement and systematic errors between the 2 methods. Mean values for EDV and ESV determined by use of MDCT were highly correlated with those determined by use of echocardiography, regardless of the calculation methods compared (r = 0.91 to 0.96); volumes determined by use of MDCT appeared to be higher than those determined by use of echocardiography, although most differences were nonsignificant. Mean EF determined by use of MDCT with the Simpson calculation method was highly correlated with that determined by use of echocardiography with bullet method calculations (r = 0.90). Results suggested that assessment of left ventricular volume and function in dogs is feasible with MDCT. To estimate left ventricular EF with MDCT. use of the Simpson calculation method is advised.

Reliability of Visual Assessment of Global and Segmental Left Ventricular Function: A Multicenter Study by the Israeli Echocardiography Research Group

ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).

Agreement of 2D transthoracic echocardiography with cardiovascular magnetic resonance imaging after ST-elevation myocardial infarction

Evaluation of Echocardiographic Measures of Left Ventricular Function in Patients with Duchenne Muscular Dystrophy: Assessment of Reproducibility and Comparison to Cardiac Magnetic Resonance Imaging

Although ejection fraction (EF) is the cornerstone of the assessment of left ventricular (LV) systolic function, its measurement faces a number of challenges related to image quality, assumptions of LV geometry, and expertise. The aim of this study was to test the inter-observer variability of EF and GLS measurement in patients with a broad spectrum of LV function, between physicians and investigators (Inv) with different levels of expertise. In 122 patients, EF and GLS were measured by 4 Inv blinded to each other with different level of experience in echocardiography; EF was measured using 3 methods: visual assessment, biplane Simpson's method, and auto-EF method. GLS was measured from the 3 apical views. A significant difference for LVEF and for LVGLS was considered to be >10 and >2 absolute values, respectively. Intra-observer agreement was excellent for visually assessed EF (ICC=0.87, P<.001) and GLS (ICC=0.82, P<.001) and good for EF measured by Simpson's method (ICC=0.70, P<.001) and auto-EF (ICC=0.72, P<.001). Intra-observer and inter-observer agreements were excellent for GLS with ICCs above 0.8. GLS discordance between the 4 Inv was not significant. Discordance in EF and GLS measurements among the Inv was not related to image quality or wall motion abnormalities. Although EF has proved its prognostic value in various cardiovascular entities, GLS seems to be more reliable for serial assessment of LV function, demonstrating lower intra- and inter-observer variability, even by different physicians with variant level of expertise.

The Evaluation Criteria in Diagnosing Ischemia with Stress and Rest Myocardial Perfusion Gated SPECT

Because of its wide availability, low cost, versatility, and clinical use, stress echocardiography has become increasingly recognized as a valuable tool in the assessment of patients with regurgitant valvular heart disease. Exercise testing is favored compared with pharmacological stress testing for risk stratification in asymptomatic patients and can identify what might otherwise be considered as a moderate valve disease. It has been shown to provide insights into exertional symptoms disproportionate to resting hemodynamics in these patients and to facilitate individual risk stratification. Aggravation of valvular regurgitation severity, exercise-induced pulmonary hypertension (PHT), impaired left ventricular (LV) contractile reserve, inducible ischemia, dynamic LV dyssynchrony, and altered exercise capacity, together with the development of symptoms during exercise echocardiography, provide the clinician with straightforward prognostic information, therefore enabling a more accurate definition of the optimal timing of intervention in patients with valvular regurgitation.1,2 In contrast, dobutamine stress echocardiography has little value in cases of valvular regurgitation. Dobutamine infusion is almost systematically associated with a decrease in the severity of regurgitation; however, it might be of interest in the detection of LV contractile reserve and inducible ischemia. The most common form of exercise used in conjunction with echocardiography is immediate postexercise imaging on a treadmill or upright bicycle ergometer. However, semisupine exercise testing on an appropriate tilted table allows continuous echocardiographic monitoring, which represents an advantageous tool for quantifying changes in valvular regurgitation severity, LV function, and pulmonary pressure (Table). This exercise stress echocardiography modality (ie, per-exercise echocardiography) is the most used in Europe, and we strongly suggest this approach in the setting of valvular heart disease to detect evanescent changes. A symptom-limited graded exercise test is recommended, and ≥80% of the age-predicted upper heart rate should be reached in the absence of symptoms. The test is adapted to the clinical conditions …

Left ventricular (LV) function is a vital parameter for prognosis, therapy guidance, and follow-up of cardiovascular disease. Dual-source computed tomography (DSCT) provides an accurate analysis of global LV function. To assess the performance of DSCT in the determination of global LV functional parameters in comparison with cardiovascular magnetic resonance (CMR) and two-dimensional transthoracic echocardiography (2D-TTE) in patients with valvular heart disease (VHD). A total of 111 patients (58 men, mean age 49.9 years) with known VHD and who underwent DSCT, 2D-TTE, and CMR a period of 2 weeks before undergoing valve surgery were included in this study. LV end-systolic volume (ESV), end-diastolic volume (EDV), stroke volume (SV), and ejection fraction (EF) were calculated by DSCT using the threshold-based technique, by 2D-TTE using a modified Simpson's method, and by CMR using Simpson's method. Agreement for parameters of LV global function was determined with the Pearson's correlation coefficient (r) and Bland-Altman analysis. All the DSCT and CMR data-sets were assessed independently by two readers. Fifty of the total 111 patients had aortic VHD, 29 patients had mitral VHD, and 32 patients had mixed aortic and mitral VHD. An excellent inter-observer agreement was seen for the assessment of global LV function using DSCT (r = 0.910-0.983) and CMR (r = 0.854-0.965). An excellent or good correlation (r = 0.93, 0.95, 0.87, and 0.71, respectively, P < 0.001) was noted between the DSCT and 2D-TTE values for EDV, ESV, SV, and EF. EDV (33.7 mL, P < 0.001), ESV (12.1 mL, P < 0.001), SV (21.2 mL, P < 0.001), and EF (1.6%, P = 0.019) were significantly overestimated by DSCT when compared with 2D-TTE. An excellent correlation (r = 0.96, 0.97, 0.91, and 0.94, respectively, P < 0.001) between DSCT and CMR was seen in the evaluation of EDV, ESV, SV, and EF. EDV (15.9 mL, P < 0.001), ESV (7.3 mL, P < 0.001), and SV (8.5 mL, P < 0.001) were significantly underestimated, but EF (1.1%, P = 0.002) was significantly overestimated by DSCT when compared with CMR. Our study showed that DSCT measurements of global LV function using the threshold-based technique were highly reproducible and compared more favorably with CMR measurements using Simpson's method than those of 2D-TTE using the modified Simpson's method. DSCT enables accurate quantification of global LV function in patients with VHD.

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).

Objectives. In grading of aortic stenosis, two-dimensional transthoracic echocardiography (2D TTE) routinely results in underestimation of the left ventricular outflow tract (LVOT) area, and hence the aortic valve area (AVA). We investigated whether three-dimensional (3D) TTE measurements of the LVOT would be more accurate. We evaluated the feasibility, agreement and inter-observer variability of 3D TTE LVOT measurements with computed tomography (CT) and Haegar sizers as reference. Design. Sixty-one patients with severe aortic stenosis were examined with 2D and 3D TTE. 41 had CT and 13 also had perioperative Haegar sizing. Pearson’s correlation and Bland-Altman plots were used to compare methods. Inter-observer variability was tested for 2D and 3D TTE. Trial registration: Current research information system in Norway (CRISTIN). Id: 555249. Results. Feasibility was 67% with 3D TTE and 100% with 2D TTE and CT. Mean LVOT area for 2D, 3D, CT and Haegar sizers were 3.7 ± 0.6 cm2, 4.0 ± 0.9 cm2, 5.2 ± 0.8 cm2 and 4.4 ± 1.0 cm2 respectively. Bias and limits of agreements for 2D TTE was 1.5 ± 1.3 cm2, compared with CT and 0.4 ± 1.5 cm2 with Haegar sizers. Corresponding results for 3D TTE were 1.2 ± 1.6 cm2 and 0.2 ± 1.8 cm2. Intraclass correlation coefficients for LVOT area were 0.62 for 3D and 0.86 for 2D. Conclusions. 2D TTE showed better feasibility and inter-observer variability in measurements of LVOT than 3D TTE. Both echocardiographic methods underestimated LVOT area compared to CT and Haegar sizers. These observations suggest that 2D TTE is still preferable to 3D TTE in the assessment of aortic stenosis.

Background and objectives: There are several methods of assessment of left ventricular function utilizing M-mode echocardiography, the most popular one being geometrically derived ejection fraction, for which its validity is compromised in case of abnormal geometry or regional wall motion abnormalities. Mitral valve E septal separation estimated by M mode echocardiography or cardiac magnetic resonance imaging can be used as an index of left ventricular systolic function assessment. The aim of this study is to assess the value of mitral valve E septal separation estimated by M mode echocardiography in evaluation of left ventricular systolic function in patients assessed in two hospitals in Erbil city. Methods: from March 2016 to May 2019, 564 patients were randomly selected in Rizgary and Erbil teaching hospitals were included in this study. For all cases; demographic data were recorded, echocardiography performed by cardiologists, ejection fraction estimated by the most appropriate method and mitral valve E septal separation estimated by M mode scanning. Results: Means of age, ejection fraction, mitral valve E septal separation were 52.4±14.8, 65.4±10.4% and 3.87±4.1 respectively. Male to female ratio was 0.64 (220/344). There was strong highly significant negative correlation between ejection fraction and E septal separation, value of 6.9 mm was the upper normal level representing ejection fraction of 55%. The sensitivity and specificity of mitral valve E septal separation more than 7 mm as a reference to low left ventricular systolic function were 100% and 99%. Conclusions: Mitral valve E septal separation is reliable and easily measurable index of assessment of left ventricular systolic function; value more than 7 mm is indicating abnormal systolic function with sensitivity of 100% and specificity of 99%.