2-dimensional Echocardiography Research Articles

Left ventricular outflow tract obstruction in patients with Ebstein anomaly

ObjectiveIn this study, we investigated the clinical characteristics of patients with Ebstein anomaly and left ventricular outflow tract (LVOT) obstruction as well as possible mechanisms of obstruction as assessed by 2-dimensional echocardiography. MethodsWe queried our institutional echocardiography and surgical databases for patients with the diagnosis of Ebstein anomaly seen from 1985 through 2022. Fourteen patients had the additional diagnosis of LVOT obstruction identified from transthoracic echocardiography. ResultsThe mean age of the 14 patients at the time that LVOT obstruction was identified was 51.9 ± 9.9 years, and 11 (78%) were female. LVOT obstruction (mean gradient 61.0 ± 25.7 mm Hg) was documented at the time of initial diagnosis of Ebstein anomaly for 8, and in the remaining, was recognized on follow-up imaging. Dynamic LVOT obstruction with systolic anterior motion (SAM) was the most common mechanism and was mostly accompanied by leftward septal movement and septal hypertrophy. Seven of the 9 patients with SAM had the diagnosis of hypertrophic cardiomyopathy. Leftward bowing of the septum appeared to be the sole cause of LVOT obstruction in 3 and a contributing factor to SAM in 4. Among the 13 patients who underwent an operation for Ebstein anomaly, 7 had concomitant septal myectomy and 3 had a subsequent procedure. ConclusionsThere are multiple mechanisms of LVOT obstruction in patients with Ebstein anomaly, including SAM and leftward bowing of the interventricular septum, which may exist alone or in combination. Septal myectomy at the time of tricuspid valvuloplasty is safe and effectively reduces gradients in the outflow tract and may prevent the need for subsequent reintervention.

Real-time Three-dimensional Echocardiography: A Feasible and Accurate Method for Measuring Right Ventricular Function in Pulmonary Hypertension

Right ventricular function is independently associated with poor clinical outcomes in patients with various cardiovascular diseases including pulmonary hypertension (PH). The complex geometry and mode of contractility means the right ventricle (RV) inlet and outlet are not in line; hence, 2-dimensional echocardiography fails to accurately quantify RV volumes and function in such patients. Three-dimensional echocardiography (3DE) allows for reliable and reproducible quantification of RV volumes and function by overcoming these limitations of conventional echocardiography. This review focuses on the 3DE assessment of RV function in patients with PH and discusses the following points: (1) acquiring an RV data set for 3DE imaging, including details of all available 3DE systems and software utilized in daily practice; (2) the reliability and feasibility of RV remodeling measured with 3DE with different modalities in patients with PH; and (3) the prognostic value of 3DE-derived RV function in such patients.

Reverse Remodeling Effects of Sacubitril-Valsartan: Structural and Functional Optimization in Stage C Heart Failure

BackgroundSacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, reduces all-cause mortality as well as the rate of heart failure hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). This study aimed to elucidate the benefits of initiating sacubitril-valsartan on ventricular remodeling in patients previously optimized on guideline directed medical therapy. MethodsIn this prospective, single-arm longitudinal study, 40 patients with HFrEF who were optimized on guideline-directed medical therapy were transitioned to sacubitril-valsartan. The primary end-point was the change in left ventricular (LV) volume at 1 year as assessed by three dimensional transthoracic echocardiography. Other echocardiographic endpoints included change in LV function and change in right ventricular (RV) size and function. ResultsThe mean age was 55 ± 12 years and 63% were male. At 1 year, LV end-diastolic volume decreased from 242 ± 71 to 157 ± 57 ml (p <0.001) with a corresponding increase in LV ejection fraction from 32 ± 7 to 44 ± 9 % (p <0.001). RV end-diastolic volume decreased from 151 ± 51 to 105 ± 45 ml (p <0.001). While RV ejection fraction did not change (51 ± 8 vs 51 ± 10; p = 0.35), RV GLS improved from -14.9 ± 3.4 % to -19.3 ± 4.3 % (p <0.001) ConclusionWhen added to standard medical therapy for heart failure, sacubitril-valsartan induces significant remodeling of both the right and left ventricles as assessed by 3D echocardiography.

Clinical Usefulness of Echocardiographic Measurement of Proximal Aortic Diameter in Early Differentiation Between Type A Acute Aortic Dissection and ST-Segment-Elevation Myocardial Infarction.

Background Contradictions between management modalities of type A acute aortic dissection (TAAAD) and ST-elevation-myocardial infarction (STEMI) may result in clinical catastrophe. Therefore, we aimed to explore which 2-dimensional echocardiography (2DE) findings are optimal for differentiating TAAAD from STEMI. Methods and Results This study included 340 patients with STEMI and 340 patients with TAAAD who underwent 2DE in the emergency department between 2012 and 2021. The proximal ascending aorta (PAA) diameter and other echocardiographic parameters were analyzed. PAA diameters were measured at 4 levels in the parasternal view: Valsalva, the sinotubular junction (STJ), the PAA at 1 cm above the STJ, and the PAA at 2 cm above the STJ. Receiver-operating characteristic curve analysis showed that Valsalva, STJ, PAA at 1 cm above the STJ, and PAA at 2 cm above the STJ were significant predictors of TAAAD (areas under the curve: 0.777, 0.924, 0.965, and 0.975, respectively; P<0.001) with the respective cutoff values of 39.4, 38.5, 39.8, and 41.2 mm. Multivariable analysis suggested that all 2DE parameters were significant predictors of TAAAD. Among the 2DE parameters examined, the incorporation of PAA at 2 cm above the STJ to clinical indicators exhibited the most significant diagnostic capability (C-statistics, 0.97; net reclassification improvement, 1.81; integrated discrimination improvement, 0.61). When only TAAAD with coronary malperfusion and STEMI were analyzed, the diagnostic utility of PAA at 1 cm above the STJ was evident (C-statistics, 0.99; net reclassification improvement, 1.79; integrated discrimination improvement, 0.67), with PAA at 2 cm above the STJ ranking second in diagnostic significance (C-statistics, 0.99; net reclassification improvement, 1.12; integrated discrimination improvement, 0.66). Conclusions PAA measurements were the most beneficial for diagnosing TAAAD in all 2DE findings and TAAAD from STEMI.

Multidetector Computed Tomography in Patients Who Underwent Transcatheter Mitral Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for mitral assessment, but its role in transcatheter mitral edge-to-edge repair (TEER) planning has been poorly elucidated. We aimed to compare MDCT with 3-dimensional transesophageal echocardiography (3D-TEE) for TEER preprocedural evaluation. We analyzed the preprocedural MDCT and 3D-TEE of 108 consecutive patients with mitral regurgitation (MR) who underwent MitraClip implantation. The levels of agreement for the etiology and mechanism of MR, mitral calcification, mitral annulus, and mitral valve orifice area (MVOA) measurements were compared between MDCT and 3D-TEE data. Receiver-operating-characteristic curves were generated for mitral annulus area and MVOA using a low mean transmitral pressure gradient at discharge (<5mm Hg) as the state variable, and the primary outcome of all-cause mortality or rehospitalization for heart failure at 1 year was compared between MDCT's and 3D-TEE's MVOA <4-cm2 cutoff. Good levels of agreement between MDCT and 3D-TEE were observed for determining the etiology (κ=0.81) and mechanism (κ=0.62) of MR but not for grading mitral calcification (κ=0.31 to 0.35). The correlations between MDCT and 3D-TEE measurements were strong for mitral annulus area (r=0.90) and good for MVOA (r=0.73). Furthermore, no significant differences in the area under the receiver-operating-characteristic curve to predict low transmitral pressure gradient at discharge or the primary outcome at 1 year were detected between MDCT- and 3D-TEE-derived parameters (all p >0.05). In conclusion, in patients who underwent TEER with MitraClip, a high degree of agreement for comprehensive evaluation of MR and prediction of clinical outcomes between MDCT and 3D-TEE was observed.

Prospective randomized controlled trial of the safety and feasibility of a novel mesenchymal precursor cell therapy in hypoplastic left heart syndrome

ObjectiveTo assess the safety and feasibility of low-dose, novel, allogenic mesenchymal precursor cell (MPC) therapy as an adjunct to left ventricular (LV) recruitment for patients with hypoplastic left heart syndrome (HLHS) and borderline left ventricles. MPC injections into the hypoplastic left ventricle may stimulate neovascularization and beneficial LV remodeling and may improve the likelihood of achieving biventricular (BiV) or 1.5 ventricle (1.5V) circulation. MethodsChildren <5 years with prior single ventricle palliation undergoing LV recruitment surgery at a single center were randomized to MPC injections into the LV endocardium/papillary muscles (MPCs) or standard-of-care (controls) and followed for 24 months. The primary endpoint was safety, including (serious) adverse events (S/AEs), and panel reactive antibodies (PRAs). Secondary endpoints included BiV/1.5V conversion and LV size and function. ResultsNineteen subjects were enrolled, including 9 MPC recipients and 10 controls. Fourteen patients (74%) had >1 AE, and 2 patients had SAEs, both deemed unrelated to the trial product. AE severity and frequency were similar in the 2 groups. Baseline PRA levels were high, with no difference between the groups at 12 months. The overall probability of BiV/1.5V conversion was 0.16 (95% confidence interval [CI], 0.05 to 0.41) at 12 months and 0.52 (95% CI, 0.31 to 0.77) at 24 months. For patients with imaging data at both time points, increases in LV volumes from baseline to 12 months were larger in the MPC group by 3-dimensional echocardiography and cardiac magnetic resonance imaging. For children who successfully underwent BiV conversion (n = 12), full BiV conversion was achieved at 24 months in 5 of 5 (100%) MPC-treated children compared with 4 of 7 (57%) controls. ConclusionsMPC injections were considered safe and feasible in HLHS patients. More than 50% of subjects underwent BiV/1.5V conversion within 2 years. Larger trials are needed to investigate the therapeutic potential of MPCs in this population.

Myocardial Strain Analysis by 2-Dimensional Speckle Tracking Echocardiography in Patients with Suspected Coronary Artery Disease

Myocardial Strain Analysis by 2-Dimensional Speckle Tracking Echocardiography in Patients with Suspected Coronary Artery Disease

Cardiological Safety of 5-Fraction Whole Breast Irradiation

Our study aims to assess heart toxic effect using a reliable cardiac assessment with standard and 3-dimensional (3D) echocardiography and left ventricular (LV) global longitudinal strain (GLS) in patients receiving a 5-fraction (total dose 26 Gy) postoperative radiation therapy (RT) for breast cancer (BC). SAFE-FORWARD is an observational prospective cohort study (NCT04842409). Inclusion criteria were: (1) patients with invasive BC receiving ultra-hypofractionated whole breast irradiation (WBI) (26 Gy in 5 fractions) after breast conserving surgery (BCS) (2) without cardiovascular comorbidity and (3) previous thoracic irradiation. All enrolled patients are prospectively monitored for 12 months, receiving a complex cardiological assessment before RT start (baseline), and at 2-, 6-, and 12-month after RT end of treatment. Both acute and early-late toxicity are evaluated according to CTCAE (v.5) scales. The primary endpoint is defined as detection of any subclinical impairment in myocardial function and deformation (decrease ≥10%) measured with standard and 3D echocardiography and LV GLS. Overall, 40 women (median age 66 years; range, 48-84) were enrolled in the study. We analyzed patients who had completed the cardiological assessment at 12 months. Baseline patient's characteristics are summarized in Table 1. All patients received ultra-hypofractionated WBI (26 Gy in 5 fractions), 25 patients also received adjuvant endocrine therapy. GLS worsened 4% or less, both for the left- and right-side treated breast, and remained in normal range for all the time points. The only exception was for RVGLS at 6 months for right-sided treatment where it reached a borderline value (-17.4±4.9 SE). 3D-LVEF remains stable during observation, both for the left- and right-side treated breast CONCLUSION: The 5-fraction schedule after BCS is well tolerated and the intensive 1-year cardiological monitoring showed no significant differences overtime in cardiac functioning. DIBH, deep inspiration breath hold; AI, aromatase inhibitors; BCCT, Breast Cancer Conservation Treatment.

3-Dimensional Multiplanar Reconstruction With Transesophageal Echocardiography for Alcohol Septal Ablation

This study described the first experience with 3-dimensional multiplanar reconstruction transesophageal echocardiography to guide percutaneous alcohol septal ablation. This study demonstrated that 3-dimensional transesophageal echocardiography multiplanar reconstruction allowed for simultaneous assessment of the targeted myocardial area from left ventricular base to apex, akin to imaging seen with spatial imaging with cardiac magnetic resonance. (Level of Difficulty: Intermediate.)

Right ventricle toxicity in cancer treatment: a focused review on cardiac imaging.

Background: The right ventricle (RV) remains the 'forgotten chamber' in the clinical assessment of cancer therapy-related cardiac dysfunction (CTRCD). Aim: We aimed to review the role that various cardiac imaging modalities play in RV assessment as part of the integrative management of patients undergoing cancer therapy. Discussion: RV assessment remains challenging by traditional 2D echocardiography. In this review we discuss other parameters such as right atrial strain, and other echocardiographic modalities such as 3D and stress echocardiography. We also elaborate on the specific role that cardiac magnetic resonance imaging and equilibrium radionuclide angiocardiography can play in assessing the RV. Conclusion: Biventricular function should be monitored following chemotherapy for early detection of subclinical CTRCD and possible solitary RV changes.

Left Ventricular Mass, Myocardial Structure, and Function in Severe Aortic Stenosis: an Echocardiographic and Cardiac Magnetic Resonance Imaging Study

In severe aortic stenosis (AS), there are conflicting data on the prognostic implications of left ventricular (LV) hypertrophy (LVH). We aimed to characterize the LV geometry, myocardial matrix structural changes, and prognostic stratification using cardiac magnetic resonance imaging (CMR) and echocardiography in subjects with severe AS with and without LVH. Consecutive patients who had severe isolated AS and sufficient quality echocardiography and CMR within 6months of each other were evaluated for LVH, cardiac structure, morphology, and late gadolinium-enhancement imaging. Kaplan-Meier curves, linear models, and proportional hazards models were used for prognostic stratification. There were 93 patients enrolled (mean age 74 ± 11years, 48% female), of whom 38 (41%) had a normal LV mass index (LVMI), 41 (44%) had LVH defined at CMR by LVMI >2 SD higher than normal, and 14 (15% of the total) with >4 SD higher than the reference LVMI (severely elevated). The Society of Thoracic Surgeons scores were similar among the LVMI groups. Compared with those with normal LVMI, patients with LVH had higher LV end-diastolic and end-systolic volumes, increased late gadolinium-enhancement burden, and lower LV ejection fraction. Most notably, CMR feature-tracking global radial strain, 2-dimensional speckle-tracking echocardiography global longitudinal strain, and left atrial reservoir function were significantly worse. On the survival analyses, LVMI was not associated with a composite of all-cause mortality and/or heart failure hospitalization. In conclusion, compared with normal LVMI, elevated LVMI was not associated with a higher risk of adverse outcomes.

Three-dimensional echocardiographic evaluation of longitudinal and non-longitudinal components of right ventricular contraction: results from the World Alliance of Societies of Echocardiography study.

Right ventricular (RV) functional assessment is mainly limited to its longitudinal contraction. Dedicated three-dimensional echocardiography (3DE) software enabled the separate assessment of the non-longitudinal components of RV ejection fraction (EF). The aims of this study were (i) to establish normal values for RV 3D-derived longitudinal, radial, and anteroposterior EF (LEF, REF, and AEF, respectively) and their relative contributions to global RVEF, (ii) to calculate 3D RV strain normal values, and (iii) to determine sex-, age-, and race-related differences in these parameters in a large group of normal subjects (WASE study). 3DE RV wide-angle datasets from 1043 prospectively enrolled healthy adult subjects were analysed to generate a 3D mesh model of the RV cavity (TomTec). Dedicated software (ReVISION) was used to analyse RV motion along the three main anatomical planes. The EF values corresponding to each plane were identified as LEF, REF, and AEF. Relative contributions were determined by dividing each EF component by the global RVEF. RV strain analysis included longitudinal, circumferential, and global area strains (GLS, GCS, and GAS, respectively). Results were categorized by sex, age (18-40, 41-65, and >65 years), and race. Absolute REF, AEF, LEF, and global RVEF were higher in women than in men (P < 0.001). With aging, both sexes exhibited a decline in all components of longitudinal shortening (P < 0.001), which was partially compensated in elderly women by an increase in radial contraction. Black subjects showed lower RVEF and GAS values compared with white and Asian subjects of the same sex (P < 0.001), and black men showed significantly higher RV radial but lower longitudinal contributions to global RVEF compared with Asian and white men. 3DE evaluation of the non-longitudinal components of RV contraction provides additional information regarding RV physiology, including sex-, age-, and race-related differences in RV contraction patterns that may prove useful in disease states involving the right ventricle.

Echocardiographic determination of right ventricular volumes and ejection fraction: Validation of a truncated cone and rhomboid pyramid formula.

Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR). 129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls. Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)). Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

Subclinical Left Ventricular Dysfunction and Ventricular Arrhythmias in Older Adults With Normal Ejection Fraction.

Background Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are known to be associated with reduced left ventricular (LV) ejection fraction and adverse outcomes in patients with structural heart disease. The relationship between subclinical LV dysfunction and ventricular arrhythmias in the general population is not established. Methods and Results Participants in the SAFARIS (Subclinical Atrial Fibrillation and Risk of Ischemic Stroke) study with normal left ventricular ejection fraction (n=503; mean age 77 years, 63% women) underwent 14-day electrocardiographic monitoring and 2-dimensional echocardiography. Frequent PVCs were defined as PVCs >500 per 24 hours and NSVT as ≥4 consecutive ventricular ectopic beats. Reduced LV global longitudinal strain (GLS) was used as an indicator of subclinical LV dysfunction. Seventy-six participants (15.1%) had PVCs >500/d, 117 (23.3%) had NSVT episodes. LV GLS was significantly reduced in both frequent PVCs and NSVT groups (P<0.01). In multivariable analyses, lower LV GLS was associated with frequent PVCs (adjusted odds ratio [aOR], 1.19 [95% CI, 1.09-1.30 per unit reduction]; P<0.001) and NSVT (aOR, 1.09 [95% CI, 1.01-1.17]; P=0.036) independently of established risk factors and other echocardiographic parameters. Abnormal LV GLS (>-15.8%) carried a 2-fold increase in risk of ventricular arrhythmias (aOR, 2.18, P=0.029 for PVCs; aOR, 2.09, P=0.026 for NSVT). Conclusions PVCs and NSVT episodes were frequent in this community-based elderly cohort with normal left ventricular ejection fraction and were independently associated with lower LV GLS. The association between LV dysfunction and ventricular arrhythmias is present at an early, subclinical stage, an observation that carries possible preventative implications.

Echocardiographic parameters recommended for assessing the severity of tricuspid regurgitation: concordance and discordance.

Current guidelines recommend integrating several echocardiographic indices to evaluate the severity of tricuspid regurgitation (TR). Discordance of indices, including qualitative and quantitative methods, commonly exists in practice. The discordance among these parameters has not yet been fully elucidated. A total of 127 patients with recognizable TR jets without pulmonary regurgitation or intracardiac shunt were prospectively enrolled. We evaluated 8 parameters by 2-dimensional (2D) echocardiography: proximal iso-velocity surface area (PISA)-derived regurgitant volume (RVol), PISA-derived effective regurgitant orifice area (EROA), PISA radius, vena contracta width (VCW), color Doppler jet area, tricuspid valve annular diameter, inferior vena cava (IVC) diameter, and peak E wave. According to current guidelines, each echocardiographic parameter was determined to represent either severe or non-severe TR. A concordance score was calculated as the number of concordant parameters divided by 8, with a higher score reflecting better concordance. Data were further categorized into 3 subgroups: complete concordance (0 discordant parameters), high concordance (1-2 discordant parameters), and low concordance (3-4 discordant parameters). The mean concordance score was 81%±17% for the entire cohort. There were 48 (38%) patients with complete concordance, including 6 patients with severe TR. In contrast, the low concordance group (n=43, 34%) mostly comprised severe TR patients (36 patients). When considering only EROA, RVol, and VCW, concordance improved, with 98 patients (77%) in complete agreement. Concordance seems limited when using echocardiographic parameters to assess TR severity. Applying only EROA, RVol, and VCW results in better concordance, as recommended by the current guidelines.

Topographical Association Between Left Ventricular Strain and Brain Lesions in Patients With Acute Ischemic Stroke and Normal Cardiac Function.

Background Although it is well known that the disordered brain provokes cardiac autonomic dysfunction, the detailed location of brain lesions related to cardiac function warrants further investigation. We aimed to elucidate the brain lesions topographically associated with left ventricular (LV) systolic function measured by myocardial strain in patients with acute ischemic stroke without preexisting primary cardiac dysfunction by using support vector regression lesion-symptom mapping. Methods and Results Subjects were those with LV ejection fraction of 50% or more among patients with acute ischemic stroke registered in the Samsung Medical Center stroke registry between 2016 and 2017. To evaluate LV systolic performance and contractility, we measured LV ejection fraction and LV global and regional longitudinal strain using 2-dimensional speckle-tracking echocardiography. The association between stroke lesion location and cardiac strain was assessed using support vector regression lesion-symptom mapping. Of a total of 776 patients, 286 subjects (mean age of 67.0 years, 65.4% men) were finally enrolled in this study. The mean global longitudinal strain was -17.0±3.4%, and the mean LV ejection fraction was 64.7±5.7%. The support vector regression lesion-symptom mapping analysis revealed that the right insula and peri-insular regions and left parietal cortex were associated with impaired LV global longitudinal strain in patients with acute ischemic stroke. In addition, impaired regional longitudinal strain showed topographical associations with these regions. Conclusions This study suggests that brain lesions in the right insula and peri-insular regions and left parietal cortex are topographically associated with impaired LV strain in patients with acute ischemic stroke without preexisting cardiac dysfunction.

Myocardial Function in Fetuses with Congenital Cytomegalovirus Infection

Introduction: The objective of this study was to investigate myocardial deformation of left (LV) and right ventricle (RV) using 2-dimensional speckle-tracking echocardiography (2D-STE) in fetuses with and without congenital cytomegalovirus (CMV) infection. Methods: This was a prospective single-center study. Vertical transmission was defined by a positive CMV polymerase chain reaction (PCR) test on the amniotic fluid or on the neonate’s urine. Fetuses were divided into group 1 and group 2 if CMV-PCR was positive or negative, respectively. LV and RV global longitudinal strain (GLS) values were obtained and adjusted for gestational age by calculating Z-scores. Univariate analysis was carried out to compare cardiac indices between group 1 and group 2. Results: Fetuses from group 1 (n = 11) had a significantly lower LV myocardial shortening than those from group 2 (n = 32). GLS was −20.7 ± 5.2% and −26.3 ± 4.1%, respectively (p = 0.001). Similarly, GLS Z-score was lower (0.02 ± 0.72) in group 1 than in group 2 (−0.80 ± 0.59) (p = 0.001). Similarly, RV GLS Z-score was significantly impaired in group 1 compared to group 2 (−0.44 ± 1.03 vs. −1.04 ± 0.71, p = 0.041). Conclusion: Fetuses with congenital CMV showed subclinical biventricular myocardial dysfunction. Further studies are needed to confirm the potential role of 2D-STE in identifying fetuses with congenital CMV at risk of postnatal cardiovascular morbidities.

Left Atrial Myopathy in Heart Failure With Preserved Ejection Fraction.

The left atrium (LA) plays an important role in facilitating left ventricular (LV) filling by acting as a reservoir, passive conduit, and active booster pump, as well as a regulator of blood volume through A-type natriuretic peptide secretion in response to stimulation by mechanical stretch of the cavity. LA myopathy has emerged as one of the most important non-LV contributors to disease progression in heart failure with preserved ejection fraction (HFpEF). LA dysfunction is common in HFpEF and is associated with more severe pulmonary vascular disease and right ventricular dysfunction, and increases the risk of incident atrial fibrillation or atrial functional mitral regurgitation, leading to limitations in cardiac output reserve and reduced exercise capacity. LA deformation assessed by 2-dimensional speckle-tracking echocardiography is useful for estimating abnormal hemodynamics or exercise capacity, discriminating HFpEF from non-cardiac dyspnea and is an independent predictor of adverse outcome in HFpEF. Thus, interventions directly targeting LA myopathy may improve outcomes in HFpEF with LA myopathy. This review provides information regarding the physiology of the LA in patients with HFpEF and discusses the importance of evaluation of LA function, management issues, and future directions through ongoing trials of medical interventions.

Early echocardiographic signs of cardiovascular affection in pediatric familial hypercholesterolemia

Familial hypercholesterolemia (FH) is a rare autosomal dominant genetic disorder caused by defective low-density lipoprotein (LDL) receptors or abnormal apolipoprotein B. FH raises the risk of premature atherosclerotic disease and cardiovascular death in young adults. However, cardiovascular affection in children needs to be more adequately studied. Our study aimed to evaluate the effect of hypercholesterolemia on the cardiovascular system of pediatric patients with homozygous FH using conventional and advanced echocardiographic parameters such as tissue Doppler imaging (TDI) and 2-dimensional speckle-tracking echocardiography (2D-STE). This case-control study matched 25 healthy children with 21 patients with homozygous FH. Both groups had conventional echocardiography, TDI, and 2D-STE. Myocardial velocities of the left and right ventricles, left ventricular strain, and aortic stiffness parameters were measured. The FH group had greater systolic blood pressure, dilated coronary arteries, and hypertrophied left ventricle (LV) compared to the control (P = 0.0001, P = 0.001, P = 0.01, respectively). The mitral E/E′ ratio was higher in the patient group than in the control group (P = 0.007), indicating LV diastolic dysfunction in patients. At the same time, LV systolic function evaluated by 2D-STE was comparable to that in the control group. The abdominal aorta circumferential strain and ascending aorta M-mode-derived strain were significantly lower in patients compared to those in the control (P = 0.024, P = 0.0001, respectively), indicating increased aortic stiffness in the patients’ group; moreover, 85.7% of patients had mild aortic insufficiency. Conclusion: Mild aortic insufficiency, coronary artery dilatation, left ventricular (LV) diastolic dysfunction, and increased aortic stiffness are among early cardiovascular markers in pediatric patients with homozygous FH before impaired LV systolic function.What is Known:• Familial hypercholesterolemia (FH) in adults is associated with accelerated atherosclerosis, aortic valvopathy, dilated coronary arteries, ischemic heart disease, and premature cardiovascular death.• The cardiovascular effects of FH in children require additional research.What is New:• Pediatric patients with familial hypercholesterolemia tend to have an early affection for left ventricular diastolic function before the affection for the systolic function.• The diastolic dysfunction associated with pediatric FH is correlated to the aortic stiffness and low-density lipoprotein levels.

Feasibility of 2-dimensional speckle tracking echocardiography strain analysis of the right ventricle with trans-thoracic echocardiography in intensive care: a literature review and meta-analysis

ObjectivesTo identify variables that affect the feasibility of 2-dimensional right ventricular speckle tracking echocardiography (RV-STE) in the intensive care unit.BackgroundTrans-thoracic echocardiography (TTE) of the right ventricle is challenging. RV-STE is a novel echocardiography method thought to measure global RV function more fully than conventional TTE parameters. The feasibility of RV-STE in ICU populations has not been well described, and variables influencing RV-STE in ICU have not been investigated. This study aimed to address this.MethodsA literature review using Ovid MEDLINE(R) was undertaken. We performed meta-analysis with subgroup analysis of; RV-STE type (RV free-wall [RVFWLS] versus RV global longitudinal strain [RVGLS]), study design (prospective versus retrospective), coronavirus disease-19 (COVID-19) study or not, and strain software used. This was followed by meta-regression of proportion of invasive mechanical ventilation (IMV), with and without COVID-19 studies as a co-variate.ResultsEleven relevant studies from the literature search were identified, reporting an overall feasibility of RV-STE of 83.3% (95%CI 74.6–89.4%). Prospective study design was associated with higher feasibility compared with retrospective studies (p = 0.02). There were no statistical differences on univariate analysis between RVFWLS versus RVGLS, COVID-19 study or not, or strain software used. Meta-regression with COVID-19 study as a covariate demonstrated that higher proportions of IMV were significantly associated with worse feasibility (p = 0.04), as were COVID-19 studies (p < 0.01).ConclusionsWe have identified three variables associated with poor feasibility; retrospective study design, COVID-19 studies, and proportion of IMV. A prospective study design should be viewed as gold standard to maximise RV-STE feasibility.