What's new in the updated American Society of Echocardiography guidelines for ultrasound-guided vascular cannulation?

Background: Left ventricular diastolic dysfunction (LVDD) is integral to diagnostics and risk stratification for both cardiac and extracardiac pathologies, such as heart failure and T2DM. LVDD is evaluated by echocardiography according to the 2016 American Society of Echocardiography (ASE) guidelines. However, without a sole identifying metric, LVDD is assessed by a diagnostic algorithm that relies on secondary characteristics, is laborious, and has potential for interobserver variability. Artificial intelligence (AI) applied to echocardiography has been shown to develop automated, reproducible workflows and detect cardiovascular diseases. Methods: To characterize concordance in clinical evaluations of LVDD, we evaluated historical echocardiogram studies at two academic medical centers for variability between clinician text reports and assessment by ASE guidelines. We then developed a workflow of 8 AI models trained on over 155,000 studies to automate assessment of LVDD (Figure 1). Model performance was evaluated on temporally distinct held-out test sets from two academic medical centers. Results: In 124,524 studies at Cedars-Sinai Medical Center (CSMC) and 1,572 studies at Stanford Healthcare (SHC), clinician assessments of diastolic function had only 30.8% agreement and 32.7% agreement with ASE guidelines, respectively. In a validation cohort of 955 studies from CSMC, our AI workflow demonstrated 76.5% agreement and a weighted Cohen’s kappa of 0.52 with ASE guideline assessment using human measurements (Figure 2). In contrast, the clinician report had 48.5% agreement and weighted kappa of 0.29 with ASE guidelines. In the SHC cohort of 1,572 studies, the AI workflow had 66.7% agreement and weighted kappa of 0.27 with ASE guidelines, while the clinician assessment had 32.7% agreement and weighted kappa of 0.06. Performance was consistent across patient subgroups by sex, age, hypertension, diabetes, obesity, and coronary artery disease (Table 1). Our AI workflow also demonstrated strong performance in predicting elevated left atrial pressure, with AUC of 0.84 and 0.76 in CSMC and SHC, respectively. Conclusion: Clinicians are often inconsistent in evaluating LVDD. We developed an AI pipeline that automates the clinical workflow of grading LVDD and has higher agreement with ASE guidelines than standard-of-care clinician evaluations. Our AI workflow can increase the efficiency and completeness of diastology, contributing to improved diagnosis of heart failure.

IntroductionLeft ventricular diastolic dysfunction (LVDD) is most commonly evaluated by echocardiography. However, without a sole identifying metric, LVDD is assessed by a diagnostic algorithm relying on secondary characteristics that is laborious and has potential for interobserver variability.MethodsTo characterize concordance in clinical evaluations of LVDD, we evaluated historical echocardiogram studies at two academic medical centers for variability between clinician text reports and assessment by 2016 American Society of Echocardiography (ASE) guidelines. We then developed a workflow of 8 artificial intelligence (AI) models trained on over 155,000 studies to automate assessment of LVDD. Model performance was evaluated on temporally distinct held-out test sets from two academic medical centers.ResultsIn a validation cohort of 955 studies from Cedars-Sinai Medical Center, our AI workflow demonstrated 76.5% agreement and a weighted Cohen’s kappa of 0.52 with ASE guideline assessment using human measurements. In contrast, the clinician report evaluation had 48.5% agreement and a weighted Cohen’s kappa of 0.29 with ASE guidelines. In the Stanford Healthcare cohort of 1,572 studies, the AI workflow had 66.7% agreement and a weighted Cohen’s kappa of 0.27 with ASE guidelines, while the clinician assessment had 32.7% agreement and a weighted Cohen’s kappa of 0.06. Performance was consistent across patient subgroups stratified by sex, age, hypertension, diabetes, obesity, and coronary artery disease.ConclusionClinicians are often inconsistent in evaluating LVDD. We developed an AI pipeline that automates the clinical workflow of grading LVDD, which can contribute to improved diagnosis of heart failure.

Left Atrial Strain and Incident Heart Failure: Validation of Left Atrium Strain-Defined Diastolic Dysfunction Grade and Comparison with Current American Society of Echocardiography Guidelines

ABSTRACTBackground and Aims:Left ventricular (LV) systolic dysfunction is a common cause of hemodynamic disturbance perioperatively and is associated with increased morbidity and mortality. Echocardiographic evaluation of left ventricular systolic function (LVSF) has great clinical utility. This study was aimed to test the hypothesis that LVSF assessed by an anesthetist using mitral valve E Point Septal Separation (EPSS) has a significant correlation with that assessed using modified Simpson's method perioperatively.Methods:This prospective observational study included 100 patients scheduled for elective surgeries. Transthoracic echocardiography (TTE) was performed preoperatively within 24 hours of surgery by an anesthetist as per American Society of Echocardiography (ASE) guidelines. EPSS measurements were obtained in parasternal long-axis view while volumetric assessment of LV ejection fraction (EF) used apical four-chamber view. Bivariate analysis of EPSS and LV EF was done by testing Pearson correlation coefficient. Receiver Operating Characteristic (ROC) curve constructed to obtain area under curve (AUC) and Youden's Index.Results:The mean value of mitral valve EPSS was 7.18 ± 3.95 mm. The calculated mean LV EF value using volumetric analysis was 56.31 ± 11.92%. LV dysfunction as per ASE guidelines is present in 28% of patients. EPSS was statistically significantly related to LV EF negatively with a Pearson coefficient of -0.74 (P < 0.0001). AUC of ROC curve 0.950 (P < 0.0001) suggesting a statistically significant correlation between EPSS and LV EF. Youden's index of EPSS value 7 mm was obtained to predict LV systolic dysfunction.Conclusion:Mitral valve EPSS shows a significant negative correlation with gold standard LVEF measurement for LVSF estimation. It can very well be used to assess LVSF perioperatively by anesthetists with brief training.

Secondary mitral regurgitation: Maintaining coherence with the American Society of Echocardiography grading guidelines, which proportionality concept best predicts prognosis in the real world?

Expert Consensus Statement from the American Society of Echocardiography on Hypersensitivity Reactions to Ultrasound Enhancing Agents in Patients with Allergy to Polyethylene Glycol

Objective This study aimed to examine the relationship between different left ventricular hypertrophy (LVH) classification criteria according to the American Society of Echocardiography (ASE), and anatomical measurement of LV wall thickness (LVWT) and histological evidence of myocyte hypertrophy. Methods Data from 146 consecutive patients (47 years; 75% were male) who have undergone heart transplantation were analysed. Fixed ventricles were dissected and measured in weight after both atria, great vessels, and epicardial fat were removed. The fixed biventricular weight was calculated as 87% of total weight (the effect of fixed formalin reduced the total weight by 3%). Anatomical LVWT was measured with a ruler at LV free wall where maximal thickness is located. A comprehensive echocardiogram was performed in all patients before heart transplantation. LVM and relative wall thickness (RWT) (2 PWT/LVEDD) were measured by M-mode echocardiography in parasternal long-axis view. Patients were considered to have LVH when the LVM index exceeds 95 g/m2 in women and exceeds 115 g/m2 in men. Patients were considered to have concentric LVH when RWT &amp;gt; 0.42. LVWT was measured using 2D echocardiography perpendicular to the LV long axis. Results Of 146 explanted hearts, dilated cardiomyopathy (CM), cardiac amyloid, and hypertrophic CM were diagnosed in 53 (47%), 1 (1%), and 8 (5%) patients, respectively. Anatomic ventricular mass correlated with echocardiographic LVM (r=0.5, p &amp;lt; 0.01). Anatomic LVWT modestly correlated with echocardiographic LVWT (r=0.2, p=0.01). Of 146 patients, echocardiographic normal LV geometry, concentric LV remodelling, concentric LVH, and eccentric LVH were present in 22 (15%), 6 (4%), 14 (10%), and 104 (71%), respectively. Increased LVWT (≥ 13 mm) assessed by 2-D echocardiography was present in normal LV geometry (5%), concentric LV remodelling (5%), concentric LVH (57%), and eccentric LVH (33%) (p &amp;lt;0.001) in those classified by ASE guidelines. Anatomic LVWT (≥ 13 mm) was present in normal LV geometry (14%), concentric LV remodelling 5%), concentric LVH (14%), and eccentric LVH (80%) (p &amp;lt;0.001) in those classified by ASE guidelines. Histological myocyte hypertrophy was present in normal LV geometry (12%), concentric LV remodelling (2%), concentric LVH (11%), and eccentric LVH (70%) (p &amp;lt;0.001) in those classified by ASE guidelines. Conclusions 2D-derived echocardiographic increased LVWT in patients with LVH defined by increased LVM index was present in approximately 30-50%. Furthermore, anatomical increased LVWT in those with LVH classified by ASE guidelines was present in a varying range of 10-70%. Patients with concentric LVH had a low prevalence of histological myocyte hypertrophy (approximately 10%). Inconsistencies in classification methods reveal the need for more robust LVH terminologies and definition that is consistent across cardiac imaging and anatomico-pathological examination, particularly in patients with CM.

Background:The correlation between normal cardiac chamber linear dimensions measured during retrospective coronary computed tomographic angiography as compared to transthoracic echocardiography using the American Society of Echocardiography guidelines is not well established.Methods:We performed a review from January 2005 to July 2011 to identify subjects with retrospective electrocardiogram-gated coronary computed tomographic angiography scans for chest pain and transthoracic echocardiography with normal cardiac structures performed within 90 days. Dimensions were manually calculated in both imaging modalities in accordance with the American Society of Echocardiography published guidelines. Left ventricular ejection fraction was calculated on echocardiography manually using the Simpson’s formula and by coronary computed tomographic angiography using the end-systolic and end-diastolic volumes.Results:We reviewed 532 studies, rejected 412 and had 120 cases for review with a median time between studies of 7 days (interquartile range (IQR25,75) = 0–22 days) with no correlation between the measurements made by coronary computed tomographic angiography and transthoracic echocardiography using Bland–Altman analysis. We generated coronary computed tomographic angiography cardiac dimension reference ranges for both genders for our population.Conclusion:Our findings represent a step towards generating cardiac chamber dimensions’ reference ranges for coronary computed tomographic angiography as compared to transthoracic echocardiography in patients with normal cardiac morphology and function using the American Society of Echocardiography guideline measurements that are commonly used by cardiologists.

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Unsupervised Machine Learning for Assessment of Left Ventricular Diastolic Function and Risk Stratification

The American College of Cardiology/American Heart Association and American Society of Echocardiography guidelines recommend assessing several echocardiographic parameters when evaluating mitral regurgitation (MR) severity. These parameters can be discordant, making the assessment of MR challenging. The degree to which echocardiographic parameters of MR severity are concordant is not well studied. We enrolled 159 patients in a prospective multicenter study. Eight parameters were included in this analysis: proximal isovelocity surface area (PISA)-derived regurgitant volume, PISA-derived effective regurgitant orifice area, vena contracta, color Doppler jet/left atrial area, left atrial volume index, left ventricular end-diastolic volume index, peak E wave, and the presence of pulmonary vein systolic reversal. Each echocardiographic parameter was determined to represent severe or nonsevere MR according to the American Society of Echocardiography guidelines. A concordance score was calculated as [Formula: see text] so that a higher score reflects greater concordance. There was no discordance when all the echocardiographic parameters agreed and high discordance when 3 or 4 parameters were discordant. The mean concordance score was 75±14% for the entire cohort. There were 9 (6%) patients with complete agreement of all parameters and 61 (38%) with high discordance. There was greater discordance in patients with severe MR but no difference between primary versus secondary or central versus eccentric jets. There was an improvement in concordance when only considering PISA-based regurgitant volume, PISA-based effective regurgitant orifice area, and vena contracta with agreement in 68% of patients. There was limited concordance between the echocardiographic parameters of MR severity, and the discordance was worse with more severe MR. Concordance improved when considering only 3 quantitative measures of vena contracta and PISA-based effective regurgitant orifice area and regurgitant volume. These findings highlight the challenges facing echocardiographers when assessing the severity of MR and emphasize the difficulty of using an integrated approach that incorporates multiple components. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04038879.

Associations between Myocardial Diastolic Dysfunction and Cardiovascular Mortality in Chronic Kidney Disease: A Large Single-Center Cohort Study

Perinatal outcomes associated with abnormal cardiac remodeling in women with treated chronic hypertension

Usefulness of Mitral Regurgitation as a Marker of Increased Risk for Death or Cardiac Transplantation in Idiopathic Dilated Cardiomyopathy in Children

Use of “Maximal Regurgitant Area” as the Sole Parameter for Evaluation of Severity of Recurrent Mitral Regurgitation After Mitral Valve Repair: Importance of the American Society of Echocardiography Guidelines