Acoustic Window Research Articles

How to standardize the measurement of left ventricular ejection fraction.

Despite recent advances in imaging for myocardial deformation, left ventricular ejection fraction (LVEF) is still the most important index for systolic function in daily practice. Its role in multiple fields (e.g., valvular heart disease, myocardial infarction, cancer therapy-related cardiac dysfunction) has been a mainstay in guidelines. In addition, assessment of LVEF is vital to clinical decision-making in patients with heart failure. However, notable limitations to LVEF include poor inter-observer reproducibility dependent on observer skill, poor acoustic windows, and variations in measurement techniques. To solve these problems, methods for standardization of LVEF by sharing reference images among observers and artificial intelligence for accurate measurements have been developed. In this review, we focus on the standardization of LVEF using reference images and automated LVEF using artificial intelligence.

Postoperative evaluation of left ventricular global strain using cardiac computed tomography in pediatric patients with congenital heart disease: A comparison with echocardiography

PurposeWe explored the feasibility and reproducibility of cardiac computed tomography (CCT)-derived left ventricular (LV) global strain in postoperative children with congenital heart disease (CHD) and compared its correlation and agreement with transthoracic echocardiography (TTE). MethodsFifty-one patients (28 males, 23 females) were included who underwent clinically indicated retrospective electrocardiography-triggered CCT. and all patients underwent additional TTE on the same day. LV global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were measured. Correlations of global strains between CCT and TTE were assessed using Pearson’s correlation coefficient. Intra-class correlation coefficients (ICC) were used to assess CCT intra-observer and inter-observer reproducibility. ResultsGLS and GCS were not significantly different between CCT and TTE (GLS: −23.54 ± 3.24 vs. −23.85 ± 3.72, respectively, p = 0.415; GCS: −28.21 ± 3.55 vs. −28.79 ± 3.69, respectively, p = 0.155). GRS was significantly different between CCT and TTE (60.79 ± 15.11 vs. 41.73 ± 4.27, respectively, p < 0.001). There was good correlation between CCT- and TTE-derived GLS (r = 0.70, p < 0.001) and GCS (r = 0.68, p < 0.001), but GRS showed no correlation between CCT and TTE (r = 0.09, p = 0.54). CCT-derived global strain showed good intra- and inter-observer reproducibility (ICC = 0.86–0.92), except the inter-observer reproducibility for GRS (ICC = 0.77). ConclusionsCCT was feasible for postoperative evaluation of LV global strain in pediatric patients with CHD with sufficient reproducibility. CCT-derived global strain can provide additional information in selected CHD patients with poor acoustic windows and who are intolerant to or have contraindications for cardiac magnetic resonance.

Comparison of compressional and elastic wave simulations for patient-specific planning prior to transcranial photoacoustic-guided neurosurgery.

.Significance: Simulations have the potential to be a powerful tool when planning the placement of photoacoustic imaging system components for surgical guidance. While elastic simulations (which include both compressional and shear waves) are expected to more accurately represent the physical transcranial acoustic wave propagation process, these simulations are more time-consuming and memory-intensive than the compressional-wave-only simulations that our group previously used to identify optimal acoustic windows for transcranial photoacoustic imaging.Aim: We present qualitative and quantitative comparisons of compressional and elastic wave simulations to determine which option is more suitable for preoperative surgical planning.Approach: Compressional and elastic photoacoustic k-Wave simulations were performed based on a computed tomography volume of a human cadaver head. Photoacoustic sources were placed in the locations of the internal carotid arteries and likely positions of neurosurgical instrument tips. Transducers received signals from three previously identified optimal acoustic windows (i.e., the ocular, nasal, and temporal regions). Target detectability, image-based target size estimates, and target-to-instrument distances were measured using the generalized contrast-to-noise ratio (gCNR), resolution, and relative source distances, respectively, for each simulation method.Results: The gCNR was equivalent between compressional and elastic simulations. The areas of the contours of point spread functions utilized to measure resolution differed by 0.33 to . Target-to-instrument distance measurements were within 1.24 mm of the true distances.Conclusions: These results indicate that it is likely sufficient to utilize the less time-consuming, less memory-intensive compressional wave simulations for presurgical planning.

Contrast-enhanced ultrasound in pediatric echocardiography.

The safety and benefits of cardiac contrast-enhanced ultrasound (CEUS) have been demonstrated in children and adolescents for a variety of clinical indications, including congenital heart disease. Cardiac CEUS is performed with US and the intravenous administration of ultrasound contrast agents (UCAs). It improves transthoracic echocardiography, which can be challenging in children and adults with acoustic window limitations (e.g., from obesity) and alterations in chest wall and cardiac geometry (e.g., from prior surgical procedures). Cardiac CEUS is also used to evaluate ischemia in the follow-up of congenital and acquired heart disease. In 2019, the United States Food and Drug Administration (FDA) approved a UCA for pediatric echocardiography. This article focuses on the clinical applications of UCAs in pediatric and adult echocardiography, outlining its diagnostic value, safety and potential for future applications.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

Left atrial strain by speckle tracking predicts atrial fibrosis in patients undergoing heart transplantation.

In patients with heart failure (HF), chronically raised left ventricular (LV) filling pressures lead to progressive left atrial (LA) dysfunction and fibrosis. We aimed to assess the correlation of LA reservoir strain (peak atrial longitudinal strain, PALS) by speckle tracking echocardiography (STE) and LA fibrosis assessed by myocardial biopsy in patients undergoing heart transplantation (HTx). Forty-eight patients with advanced HF [mean age 51.2 ± 8.1 years, 29% females; LV ejection fraction ≤25% and New York Heart Association (NYHA) class III-IV] referred for HTx were enrolled and underwent pre-operative echocardiographic evaluation, right heart catheterization, and cardiopulmonary exercise testing. Exclusion criteria were non-sinus rhythm, mechanical ventilation, severe mitral/tricuspid regurgitation, or other valvular disease and poor acoustic window. After HTx, LA bioptic samples were collected and analysed to determine the extent of myocardial fibrosis (%). LA fibrosis showed correlation with PALS (R = -0.88, P < 0.0001), VO2max (R = -0.68, P < 0.0001), NYHA class (R = 0.66, P < 0.0001), LA stiffness (R = 0.58, P = 0.0002), and E/e' (R = 0.44, P = 0.005), while poorly correlated with E/A ratio (R = 0.23, P = 0.21). PALS had a good correlation with NYHA class (R = -0.64, P < 0.0001), PAoP (R = -0.61, P = 0.03) and VO2max (R = 0.57, P = 0.0001). Multivariate regression analysis identified PALS (beta = -0.91, P < 0.001) and LA Volume (beta = -0.19, P = 0.03) as predictors of LA Fibrosis, while E/e' was not a significant predictor (beta = 0.15, P = 0.08). Emerging as a possible index of myocardial fibrosis in patients with advanced HF, PALS could help to optimize the management and the selection of those patients with irreversible LA structural damage for advanced therapeutic strategies.

Usefulness of a multiparametric evaluation including global longitudinal strain for an early diagnosis of acute myocarditis

Cardiac magnetic resonance imaging (CMRI) represents the main imaging modality for diagnosing acute myocarditis. However, its limited availability could entail missing or delayed diagnosis. A reduction of left ventricular global longitudinal strain (LV GLS) by speckle tracking echocardiography (STE) correlates with amount of oedema in acute myocarditis and here may be early detected. Aim was to evaluate the diagnostic and prognostic role of 3-layers LV GLS in patients with acute myocarditis. Out of 122 patients with suspected acute myocarditis, a total of 86 consecutive patients with CMRI-confirmed acute myocarditis admitted in two Italian institutions were retrospectively screened. Exclusion criteria were met in 29 patients because of poor acoustic window or missing data. A total of 57 patients were then included. Clinical characteristics, laboratory examinations, transthoracic echocardiography data and STE parameters were collected early after hospitalization. In the study population, mean age was 38.8 ± 15.6 years, the prevalence of male gender was 90%. On admission, 22 patients (39%) had fever (body temperature > 37.5 °), mean white blood cell (WBC) count was 10.9 ± 1.7/10^3 and overall LV ejection fraction was 50.1% ± 11.2. An epicardial LV GLS < 18% was present in 74% of patients, and a model including at least one of LV GLS < 18% (absolute value), fever and WBC > 10.0/10^3 was able to identify all patients with CMRI-diagnosed acute myocarditis. An epicardial LV GLS < 15.3% (absolute value) at baseline significantly predicted the lack of myocarditis resolution during follow-up (AUC 0.76, 95% CI 0.58–0.93, p = 0.02). A multiparametric model including epicardial LV GLS, fever and elevated WBC count on admission could be useful for early diagnosing an acute myocarditis, especially when CMRI is not promptly available. Baseline epicardial LV GLS may also identify patients with less-likely myocarditis resolution.

Multi-plane echocardiographic assessment of right ventricular function in adults with repaired Tetralogy of Fallot

In patients with repaired Tetralogy of Fallot (ToF), detailed assessment of right ventricular (RV) function is important for management and timing of possible pulmonary valve re-intervention. The aim of this study was to evaluate RV function using two-dimensional multi-plane echocardiography (2D MPE), a novel four-wall imaging method obtained from one apical acoustic window utilising electronic plane rotation. In sixty-two ToF patients (aged - 28 [22, 39] years, 65% male), systolic function of four different RV walls (lateral, anterior, inferior and inferior coronal) were evaluated using MPE. Tricuspid annular plane systolic excursion (TAPSE), tricuspid annular peak systolic velocity (RV-S′) and RV wall longitudinal strain (RV-LS) measurements were compared with those of matched healthy individuals. 2D MPE measurements were highly feasible across the four RV walls (93.5–100% for TAPSE/S′; 66.1–95.1% for RVLS) and could be performed more reliably than 3D RV ejection fraction (RVEF − 56.5%). All functional values were significantly reduced when compared to the control group (p < 0.001). Higher RV-LS values were seen in the lateral (− 17.8 ± 4.5%) and inferior (− 17.8 ± 4.2%) walls compared to the anterior (− 15.9 ± 3.8%) and inferior coronal (− 15.1 ± 3.9%) walls. 3D RVEF correlated strongest with RV-LS values from the lateral (r − 0.50; p = 0.002) and anterior walls (r − 0.74; p < 0.001) and furthermore the four-wall average (r − 0.57; p = 0.001). 2D MPE evaluation of the RV is highly feasible in ToF patients. This novel method provides new insights into regional RV wall function, enabling a more comprehensive and quantitative approach to RV assessment in daily clinical practice.

Transabdominal ultrasonographic measurement of caudal vena cava to aorta derived ratios in clinically healthy neonatal foals

BackgroundUltrasonographic measurement of the vena cava and aorta (Ao) diameters and their ratios have been suggested to be a reliable way of quantifying hypovolemia.ObjectiveTo evaluate the feasibility and reliability of an ultrasonographic technique for measurement of Ao and caudal vena cava (CVC) and derived ratios using three different acoustic windows in a population of healthy neonatal foals. Correlation between Ao and CVC measurements and ratios and foals' age or bodyweight were also investigated.MethodsIn 14 healthy foals aged less than 7 days, the diameters of the Ao and of the CVC in long and short axis were measured by two observers from images obtained using three different ultrasonographic imaging planes (left dorsal, left ventral and right views). The Ao and CVC cross‐sectional area and the CVC/Ao diameter and area ratios were calculated. Image quality was subjectively assessed. Intraobserver and interobserver reliabilities for image quality scores and measurements were evaluated between the two observers. Simple linear regression models were used to identify correlations between the CVC/Ao measurements and ratios and the age and bodyweight of the foals.ResultsThe left ventral view showed the highest reliability. A correlation between bodyweight and the short axis measurement of the CVC was found (R 2 = 0.385; p = 0.018). Age was positively correlated with the long axis of measurement of the CVC (R 2 = 0.426; p = 0.011) and CVC/Ao diameter ratio (R 2 = 0.625; p = 0.001).ConclusionsThe left ventral view allows the Ao and CVC cross sections to be easily visualized and measured in neonatal foals in right lateral recumbency.

Comparison of Thoracic Epidural Access with Lateral Decubitus and Shoulder Rotation Positions for Repeat Thoracic Epidural Blockade

Shoulder rotation has been shown to increase the acoustic window of ultrasound for thoracic epidural access. However, this effect of shoulder rotation has not yet been confirmed in clinical practice. This study aimed to evaluate the effects of shoulder rotation on the thoracic epidural blockade in patients with acute or chronic pain in the thoracic region. Prospective crossover trial. Pain clinic of our university in the Republic of Korea. Forty patients aged 20 - 80 years with acute or chronic pain in the thoracic region who were scheduled to undergo thoracic epidural blockade more than twice. The patients underwent repeated fluoroscopy-guided thoracic epidural blockade via the paramedian approach in the lateral decubitus position either with or without shoulder rotation.The primary outcome measure was the attempt time to the confirmed spread of contrast. The number of attempts, total procedure time, vertical interpedicular distance, contrast spreading length, and complications were compared between the 2 positions. The median attempt times in the lateral decubitus and shoulder rotation positions were 138.8 and 132.5 seconds, respectively, and this difference was significant (P = 0.004). Compared with the lateral decubitus position, the shoulder rotation position was also associated with a significantly lower number of attempts (P = 0.03), shorter total procedure time (P < 0.001), and greater vertical interpedicular and contrast spreading distances (P < 0.001 and P = 0.02, respectively). The operator in this study was not blinded to the patient groups. Other researchers observed the operator's procedure and evaluated and recorded the data in an attempt to overcome this bias. However, it was difficult to completely avoid the bias. Second, epidural blockade was performed at various levels (T3-11), and the anatomical features vary among thoracic spine levels. The study findings demonstrate the clinical benefits of the shoulder rotation position versus the lateral decubitus position in terms of successful epidural access during thoracic epidural blockade using the paramedian approach.

Indian Academy of Echocardiography Guidelines for Performance of Transesophageal Echocardiography in Adults

Transesophageal echocardiography (TEE) has unique advantages over conventional transthoracic echocardiography (TTE). Compared with TTE, TEE generally provides excellent quality images, especially of the posteriorly situated cardiac structures, such as atria, pulmonary veins, mitral valve, and left atrial appendage. TEE also offers a useful alternative to TTE in patients in whom transthoracic acoustic windows are suboptimal. Furthermore, TEE is the most suited imaging modality for use in the operating rooms and cardiac catheterization labs for guiding cardiac surgical or interventional procedures. However, specific training and competence are required for performing TEE successfully, smoothly, safely and with minimum patient discomfort. This document describes the basic principles of TEE examination, including patient selection and preparation, periprocedural monitoring, and probe handling and maneuvers. Commonly recommended views and the techniques to obtain these views are described in detail, followed by evaluation of specific cardiac structures. Finally, the role of TEE in certain specific clinical settings, such as during advanced circulatory support, is also discussed.

Transthoracic echocardiogram by protocol apical-subcostal in prone position during invasive mechanical ventilation

Funding AcknowledgementsType of funding sources: None.IntroductionDuring COVID-19 pandemic reports increased of transthoracic echocardiography (TTE) in prone and invasive mechanical ventilation (IMV), mostly describing four and five chamber apical views, and inferior vena cava (IVC) by lateral IVC window (from right side of the patient).PurposeEvaluate quality of images obtained with protocol of apical-subcostal TTE in patients with IMV and prone position.MethodsProspective study, between August and December 2020, in adults who required prone position during IMV. After placing the patient in the prone position, left arm was extended overhead, and a pillow was placed only under the left hemithorax to elevate and facilitate the apical window and space below the patient for subcostal window. Operator stands on the left side of the patient and takes images with the transducer in your right hand, starting with apical window and subsequently subcostal window. Apical views were apical four, two and three-chambers, to obtain function parameter of right and left ventricle (LV), evaluation of aortic valve, mitral and tricuspid valve. Subcostal views were four cardiac chambers and IVC, to obtain qualitative ventricle function, presence of pericardial effusion, and volume status and estimation of pulmonary pressure (together to peak systolic tricuspid pressure gradient from apical views). The images were acquired by cardiologist, then were saved, and finally evaluated by two echocardiography cardiologist experts.Results16 ETTs were performed. Male gender and obesity predominate. Positive end-expiratory pressure average was 10.8 cm of water. One patient cannot be assessed by absence of acoustic window and the rest (n = 15) were analyzed with experts. It was achieved a four-chamber apical view in 100% (n = 15), a two-chambers apical view in 60% (n = 9) and a three-chambers apical view in 100% (n = 15). It was possible to assess global function of the LV in 100% (n = 15), LV segmental function in 53% (n = 8), LV outflow tract velocity time integral in 100% (n = 15) and tricuspid annular plane systolic excursion in 100% (n = 15). Pulsed wave doppler of mitral valve in 100% (n = 15) and tissue doppler of lateral mitral valve annulus 100% (n = 15). Continuous wave doppler of aortic valve in 100% (n = 15) and tricuspid valve in 93% (n = 14). Subcostal four-chamber 80% (n = 12), presence pericardial effusion 100% (n = 15) and IVC 93% (n = 14). Non-complications associated with obtaining the position.ConclusionsETT in the prone position during IMV was possible and interpretable images were achieved. The position described allows assessment by apical and subcostal views at the same time and position of the operator and the patient. In addition, it was a safe technique, and the position was easy to be incorporated by the health team. Limitations were obtaining the two-chamber apical view and evaluation of segmental alterations of the LV. Better validation requires a larger sample.

Utility of Fetal Cardiovascular Magnetic Resonance for Prenatal Diagnosis of Complex Congenital Heart Defects

Prenatal diagnosis of complex congenital heart defects reduces mortality and morbidity in affected infants. However, fetal echocardiography can be limited by poor acoustic windows, and there is a need for improved diagnostic methods. To assess the clinical utility of fetal cardiovascular magnetic resonance imaging in cases in which fetal echocardiography could not visualize all relevant anatomy. This cohort study was conducted between January 20, 2017, and June 29, 2020, at Skåne University Hospital (Lund, Sweden), a tertiary center for pediatric cardiology and thoracic surgery. Participants were fetuses referred for fetal cardiovascular magnetic resonance examination by a pediatric cardiologist after an inconclusive echocardiograph. Fetal cardiovascular magnetic resonance examination requested by the patient's pediatric cardiologist. Any change in patient management because of diagnostic information gained from fetal cardiovascular magnetic resonance imaging. A total of 31 fetuses underwent cardiovascular magnetic resonance examination at a median gestational age of 36 weeks (range, 31-39 weeks). Overall, fetal cardiovascular magnetic resonance imaging had clinical utility, affecting patient management and/or parental counseling in 26 cases (84%). For aortic arch anatomy including signs of coarctation (20 fetuses), fetal cardiovascular magnetic resonance imaging added diagnostic information in 16 cases (80%). For assessment of univentricular vs biventricular outcome in borderline left ventricle, unbalanced atrioventricular septal defect, and pulmonary atresia with intact ventricular septum (15 fetuses), fetal cardiovascular magnetic resonance imaging visualized intracardiac anatomy and ventricular function, allowing assessment of outcome in 13 cases (87%). In 4 fetuses with hypoplastic left heart syndrome, fetal cardiovascular magnetic resonance imaging helped delivery planning in 3 cases (75%). Finally, fetal cardiovascular magnetic resonance imaging provided valuable information for parental counseling in 21 cases (68%). In this cohort study, fetal cardiovascular magnetic resonance imaging added clinically useful information to what was available from echocardiography. These findings suggest that fetal CMR has the potential to affect clinical decision-making in challenging cases of congenital heart defects with inconclusive data from echocardiography. Fetal cardiovascular magnetic resonance imaging showed an association with clinical decision-making, including mode of delivery and early postnatal care, as well as with parental counseling.

Femoral Vein Pulsatility: What Does It Mean?

In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.

Technical and clinical study of x-ray-based surface echo probe tracking using an attached fiducial apparatus.

Several types of structural heart intervention (SHI) use information from multiple imaging modalities to complete an interventional task. For example, in transcatheter aortic valve replacement (TAVR), placement and deployment of a bioprosthetic aortic valve in the aorta is primarily guided by x-ray fluoroscopy (XRF), and echocardiography provides visualization of cardiac anatomy and blood flow. However, simultaneous interpretation of independent x-ray and echo displays remains a challenge for the interventionalist. The purpose of this work was to develop a novel echo/x-ray co-registration solution in which volumetric transthoracic echo (TTE) is transformed to the x-ray coordinate system by tracking the three-dimensional (3D) pose of a probe fiducial attachment from its appearance in two-dimensional (2D) x-ray images. A fiducial attachment for a commercial TTE probe consisting of rings of high-contrast ball bearings was designed and fabricated. The 3D pose (position and orientation) of the fiducial attachment is estimated from a 2D x-ray image using an algorithm in which a virtual point cloud model of the attachment is iteratively rotated, translated, and forward-projected onto the image until the average sum-of-squares of grayscale values at the projected points is minimized. Fiducial registration error (FRE) and target registration error (TRE) of this approach were evaluated in phantom studies using TAVR-relevant gantry orientations and four standard acoustic windows for the TTE probe. A patient study was conducted to assess the clinical suitability of the fiducial attachment prototype during TTE imaging of patients undergoing SHI. TTE image quality for the task of guiding a transcatheter procedure was evaluated in a reviewer study. The 3D FRE ranged from 0.32±0.03mm (mean±SD) to 1.31±0.05mm, depending on C-arm orientation and probe acoustic window. The 3D TRE ranged from 1.06±0.03mm to 2.42±0.06mm. Fiducial pose estimation was stable when >75% of the fiducial markers were visible in the x-ray image. A panel of reviewers graded the presentation of heart valves in TTE images from 48 SHI patients. While valve presentation did not differ significantly between acoustic windows (P>0.05), the mitral valve did achieve a significantly higher image quality compared to the aortic and tricuspid valves (P<0.001). Overall, reviewers perceived sufficient image quality in 76.5% of images of the mitral valve, 54.9% of images of the aortic valve, and 48.6% of images of the tricuspid valve. Fiducial-based tracking of a commercial TTE probe is compatible with clinical SHI workflows and yields 3D target registration error of less than 2.5mm for a variety of x-ray gantry geometries and echo probe acoustic windows. Although TTE image quality with respect to target valve anatomy was sufficient for the majority of cases examined, prescreening of patients for sufficient TTE quality would be helpful.

An uncommon cause of nerve stimulator’s malfunction during a dual guidance lumbar plexus block: A technical brief report and an algorithm for prevention of complications

Posterior Lumbar plexus block (PLPB) combined with an ipsilateral sacral plexus block is a valuable anaesthetic technique in patients undergoing hip fracture surgery. PLPB is performed through the acoustic window of the lumbar ultrasound trident and the position of the needle tip, before injection of LA, was confirmed by observing quadriceps femoris muscle contraction to peripheral nerve stimulation (i.e., dual guidance). We report an uncommon cause of nerve stimulator malfunction that might impair block performance and promote complications. We add an algorithm to limit the risk of complications.

Role of transcranial ultrasound augmented by color Doppler study in evaluation neonatal brain problem in preterm patient

Background: It is well known that the number of surviving preterm infants is today steadily rising. In spite of the improvements in perinatal medicine, brain injury is still a major clinical problem and remains an important cause of perinatal morbidity and mortality. The main aim to assess the significance of universal cranial ultrasound screening in all preterm neonates in the neonatal ICU with gestational age between 28 and 37 weeks of gestational age even if clinically silent. Methods: 100 preterm neonate were examined by cranial doppler ultrasound at radiology department of Benha Children Hospital (BENCH). 52 of them were male patient and 48 were female. The age ranging from 28 to 37 weeks (early neonate from 28 to 32 weeks and moderate & late neonate from 32 to 37 weeks, using two transducer probes, convex Array transducer (6 MHz) and Linear Array transducer (7.5 MHz). The anterior fontanel was used as the principal acoustic window. Results: Through the scheduled study period, 100 preterm neonates were examined by convex array transducer and linear array transducer, the anterior fontanel was used as the principal acoustic window, 52% of them were male patients and 48% were female patients, with age ranging from 28 to 37 weeks classified as group I > 32 weeks represent 44% and group II ≥ 32 weeks represent 56%. Conclusion: Cranial ultrasound was proven to have a significant role in evaluation neonatal brain problems in preterm patients while most of abnormal brain scans are usually asymptomatic patients.

Echocardiographic pre-pause imaging and identifying the acoustic window during CPR reduces CPR pause time during ACLS – A prospective Cohort Study

ObjectivesPre-pause imaging during cardiopulmonary resuscitation (CPR) involves the acquisition of poor-quality, brief images immediately prior to stopping CPR to allow shorter, better-quality images during the pause. We hypothesize that pre-pause imaging is associated with a decrease in CPR pause length and shorter image acquisition time. MethodsProspective, interventional cohort study enrolling out-of-hospital (OOH) cardiac arrest patients. Pre-pause imaging involves pre-localizing of the approximate sonographic window during CPR to support subsequent fine tuning when CPR pauses. Physicians were educated on pre-pause imaging and data was recorded prior- and post- introduction of pre-pause imaging into American cardiac life support (ACLS). Timing of CPR pauses and identification of interventions and events during pause were recorded (e.g., intubation, defibrillation, multiple cardiac ultrasounds). Ultrasound (US) images were reviewed for image quality using a 5-point scale. Primary outcome was length of CPR pause with and without pre-pause imaging. Secondary outcome included US length. ResultsOne hundred and forty five subjects presenting after OOH cardiac arrest were enrolled over 13 months, 70 during the baseline period prior to pre-pause imaging and 75 after pre-pause imaging was integrated into ACLS. Pre-pause imaging decreased CPR pause length from 28.3s (95%CI 25.1–31.5) to 12.8s (95%CI 11.9–13.7). US image acquisition time decreased with pre-pause imaging from 20.4 (95%CI 18.0–22.7) to 11.0s (95%CI 10.1–11.8). US image quality was unchanged despite the decrease in image acquisition time. (3.0 (95%CI 2.8–3.2) vs 2.7 (95%CI 2.5–2.9)). Multivariate modeling showed that ultrasound did not prolong CPR pause length. ConclusionPre-pause imaging was associated with significant decrease in CPR pause length and US image acquisition time. Pre-pause imaging should be encouraged for any clinicians who use ultrasound during ACLS.

Cardiovascular Imaging in Obesity.

Obesity represents one of the most challenging public health problems of our century. It accounts for approximately 5% of deaths worldwide, mostly owing to cardiovascular disease and its associated complications. Cardiovascular noninvasive imaging may provide early accurate information about hypertrophy and ischemia/fibrosis in obese subjects. Echocardiography and nuclear cardiology have serious limitations in obese subjects owing to poor acoustic window and attenuation artifacts, respectively. Coronary computed tomography angiography can provide information about obstructive coronary disease; however, the use of radiation is a serious disadvantage. Finally, cardiac magnetic resonance (CMR) holds the promise of an “all in one” examination by combining evaluation of function, wall motion/thickness, stress rest/perfusion, replacement and diffuse fibrosis without radiation. Future studies are required to document the cost/benefit ratio of the CMR in the evaluation of cardiovascular risk in overweight/obese children and adolescents.

Echocardiographic Screening of Anomalous Origin of Coronary Arteries in Athletes with a Focus on High Take-Off

Anomalous aortic origin of coronary arteries (AAOCA) represents a rare congenital heart disease. However, this disease is the second most common cause of sudden cardiac death in apparently healthy athletes. The aim of this systematic review is to analyze the feasibility and the detection rate of AAOCA by echocardiography in children and adults. A literature search was performed within the National Library of Medicine using the following keywords: coronary artery origin anomalies and echocardiography; then, the search was redefined by adding the keywords: athletes, children, and high take-off. Nine echocardiographic studies investigating AAOCA and a total of 33,592 children and adults (age range: 12–49 years) were included in this review. Of these, 6599 were athletes (12–49 years). All studies demonstrated a high feasibility and accuracy of echocardiography for the evaluation of coronary arteries origin as well as their proximal tracts. However, some limitations exist: the incidence of AAOCA varied from 0.09% to 0.39% (up to 0.76%) and was lower than described in computed tomography series (0.3–1.8%). Furthermore, echocardiographic views for the evaluation of AAOCA and the definition of “minor” defects (e.g., high take-off coronary arteries) have not been standardized. An echocardiographic protocol to diagnose the high take-off of coronary arteries is proposed in this article. In conclusion, the screening of AAOCA by echocardiography is feasible and accurate when appropriate examinations are performed; however, specific acoustic windows and definitions of defects other than AAOCA need to be standardized to improve sensitivity and specificity.