American Society Of Echocardiography Research Articles

Echocardiographic Evaluation of Chronic Aortic Regurgitation: Comparison With Cardiac Magnetic Resonance and Implications for Guideline Recommendations.

Guidelines for echocardiographic evaluation of aortic regurgitation (AR) have not been validated against an independent quantitative standard. The aim of this study was to evaluate the accuracy of the ASE (American Society of Echocardiography) AR guidelines against cardiac magnetic resonance (CMR) and to develop simplified approaches for detection of significant AR. Patients with AR underwent echocardiography and CMR<4 hours apart. AR severity was graded according to ASE guidelines. Quantitation of regurgitant volume (RegV) was performed with pulsed Doppler at the mitral annulus and right ventricular outflow compared with left ventricular (LV) outflow, and with proximal isovelocity surface area. The authors studied 81 patients; median age was 52 years, and 58% had a bicuspid aortic valve. According to echo, 35 (43%) patients had mild AR, 18 (22%) moderate, 12 (15%) moderate to severe, and 16 (20%) had severe AR. The area under the curve (AUC) for detection of severe AR by CMR using ASE grading was 0.9 (82.4% sensitivity and 96.9% specificity). Feasibility of RegV quantitation was >88% using either echo volumetric method, and it was low for proximal isovelocity surface area (37%). The highest accuracy for echo parameters against CMR was seen with vena contracta width, jet width, and LV end-diastolic volume index (AUC: 0.86-0.89); pressure half-time had the lowest accuracy. Without RegV quantitation, a vena contracta width≥0.5cm and indexed LV end-diastolic volume≥82mL/m2 had 95.5% positive predictive value and 87.5% negative predictive value for identifying≥moderate to severe AR by CMR (AUC: 0.89). The ASE guidelines display very good performance in identifying significant AR. A simplified approach using vena contracta width and LV volumes can be used to reliably identify significant AR. Further validation of the findings in larger cohorts and against clinical outcomes is needed.

Speeding up echocardiographic examination by automated generation of 2D imaging views from 3D volumetric data using machine learning

Abstract Background 3D echocardiographic data contain infinite 2D echocardiographic planes generated by multiplanar reconstruction, but the process is labor-intensive and time-consuming. Artificial intelligence (AI) utilizing cutting-edge machine learning techniques may improve the accuracy and efficiency of the process. In the study, we developed and validated an AI software that automatically reconstructs 7 2D views recommended by the American Society of Echocardiography from 3D echocardiographic data. Method Convolutional neural network (CNN) architecture utilizing Spatial Configuration Net was used as the machine learning model. We identify a minimum of 3 key feature landmarks on each 2D cross-sectional plane, with the 3D coordinates representing 2D cross-sectional planes accordingly. Subsequently, these landmarks are accurately labeled within a 3D space. 31 landmarks were identified across 7 2D cross-sectional planes and a total of 472 3D volume data were labelled. The performance of the model is evaluated by Root Mean Square Error (RMSE) of the predicted landmark coordinates. Results The mean RMSE over 31 predicted landmarks evaluated in testing is 2.70% for the input 3D volume dimensions. The average time used to generate the 7 2D imaging views was 19.91±3.19 seconds (figure). Conclusion The AI algorithm can efficiently convert 3D echocardiographic data into guideline-recommended 2D images, which shortens the length of echo examination but still preserves the accuracy.AI generation of 2D views from 3D echo

Left atrial strain demonstrates the ability to distinguish patients with pre and post-capillary pulmonary hypertension

Abstract Background The characterization of pulmonary hypertension (PH) patients into pre or postcapillary (pcPH)phenotypes poses a challenge during screening due to the ambiguity surrounding their comorbidities. This distinction is crucial as it influences treatment decisions and prognostication. Purpose Investigating Left Atrial Strain as a Discriminant Marker for Distinguishing Pre and Post-Capillary PH. Methods Out of 164 patients exhibiting both pre- and post-capillary phenotypes, 97 had optimal left atrial 2D strain. Left atrial 2D strain was performed with a GE Vivid9 ultrasound machine equipped with dedicated software, ensuring meticulous attention to image quality and region of interest thickness restricted to a maximum of 6 mm. Subsequently, the peak left atrial strain during reservoir function was quantified as part of the investigation. To determine the optimal cut-off value, ROC curve analysis was employed. Results 60 patients had pcPH while 37 had pre-capillary PH. Mean age was 65±12y. Mean pulmonary artery pressure, wedge pressure, cardiac output and pulmonary vascular resistance averaged 40,9±10,7 mm Hg, 15,7±8,7 mm Hg, 5,9±2,0 l/min and 4,7±3,1 WU, respectively. Left atrial 2D strain ranged from +2,5% to 60%, with a mean of +18,2±11,2%. From ROC cure analysis, patients with LA 2D strain &amp;gt; +19,1% had a precapillary phenotype with a sensitivity and a specifity of 93% and 88% respectively (Fig 1). Left atrial 2D strain demonstrates higher sensitivity compared to various parameters, such as scores from the European Society of Respiratory Disease, left ventricular end-diastolic pressure estimation from the American Society of Echocardiography, HFA-PEFF score, and H2FPEF from the AHA. Conclusion Left atrial 2D strain demonstrates superior sensitivity in distinguishing between patients with pre and post-capillary pulmonary hypertension compared to other assessment methods.FIG 1:Left atrial 2D strainFig 2:SENS of parameters and scores

Left atrial reservoir strain as a prognostic indicator for cardiovascular events after mitral valvuloplasty

Abstract Background In patients after mitral valvuloplasty (MVP), assessing valve function and heart failure (HF) is crucial for prognostic predictions. Left ventricular diastolic function assessed by transthoracic echocardiography (TTE) plays an important role in the evaluation of HF in general practice. However, post-mitral valve surgery patients are excluded from the left ventricular diastolic function assessment guidelines proposed by the American Society of Echocardiography in 2016 due to their low correlation with left ventricular diastolic function indices. On the contrary, the left atrial reservoir strain (LARS) before MVP is considered as a prognostic factor, reflecting left atrial dysfunction caused by mitral regurgitation. Nevertheless, there are limited reports on the relationship between LARS and cardiovascular (CV) events after MVP. Purpose The study aims to investigate the utility of LARS in predicting CV events after MVP. Methods The study included 249 patients who underwent TTE between January 2011 and January 2023 after MVP at our hospital. Patient background data, including NYHA classification, medical history, medications, blood tests, and TTE data, were collected at the time of follow-up TTE. LARS, left ventricular global longitudinal strain (LV-GLS), and right ventricular free wall strain (RV-FWSL) analysis were performed using a vender-independent external strain analysis software for all patients in the cohort. The primary endpoints were cardiovascular death and HF rehospitalization. The predictor of cardiovascular events was assessed using the Cox proportional hazards model and Kaplan-Meier curve (KMC). Results The mean age was 61±14 years, and 159 patients (64%) were male. The median time from surgery to TTE was 4.8 (1.0-6.8) years, 32 patients (13%) had events within 8.5 (3.7-10.8) years after TTE. The event groups had higher age, NYHA classification, and NT-pro BNP compared to the non-event group. TTE parameters such as left ventricular mass index, left ventricular end-diastolic volume and end-systolic volume were larger, and LV-GLS and LARS were significantly lower in the event group. In multivariate Cox proportional hazards models showed that LARS was also a prognostic indicator even after adjustment for several variables (Table 1). The KMC showed that LARS was associated with events regardless of left atrial volume index (Log-rank p &amp;lt;0.001, chi-square:31.03) (Figure 1). Conclusion LARS was strongly associated with CV events after MVP. We consider LARS to be a useful prognostic indicator after MVP.

Left ventricular hypertrophy, wall thickness, and histological myocyte alteration in end-stage heart failure: a call for a standard definition

Abstract 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.

The Agreement Between Transthoracic and Transesophageal Echocardiography in the Assessment of Right Ventricular Diastolic Dysfunction Grades in Adult Patients Undergoing Cardiac Surgery: A Prospective Observational Study.

Introduction The importance of right ventricular (RV) diastolic function in cardiac surgery cannot be overstated, as it significantly affects prognosis and long-term outcomes. Conventionally, RV diastolic dysfunction (RVDD) is assessed and graded using criteria from either the American Society of Echocardiography (ASE) or the British Society of Echocardiography (BSE), with measurements done by transthoracic echocardiography (TTE). However, during cardiac surgery, perioperative echocardiographic evaluation is done predominantly by transesophageal echocardiography (TEE). This study aimed to assess the agreement between TTE and TEE in grading RVDD using both ASE and BSE criteria. Methods Key two-dimensional (2D) and Doppler parameters were measured in 81 patients undergoing cardiac surgery by both TTE and TEE after anesthesia induction within 10 minutes of each other, under similar hemodynamic, anesthetic, and ventilatory conditions. RVDD gradings were done separately by TTE and TEE with both ASE and BSE criteria using the measured values of the key parameters by TTE and TEE, respectively. RVDD gradings derived from TTE were compared with those derived from TEE. The tricuspid inflow Doppler and tricuspid annular tissue Doppler parameters were measured in TEE in both mid-esophageal RV inflow-outflow (MERVIO) and deep transgastric RV inflow-outflow (DTGRVIO) views. Gradings were done separately for both views of TEE by using the Doppler values measured in the respective views (TEE-MERVIO and TEE-DTGRVIO). The TTE-derived RVDD grades were compared with those derived by both TEE-MERVIO and TEE-DTGRVIO. Weighted κ values were used to assess observed agreement beyond chance. Inter-rater reliability of the RVDD grades derived by both TTE and TEE (both views) was also checked. Individual 2D and Doppler parameters were compared between TTE and TEE in terms of Bland-Altman limits of agreement. Results As per ASE criteria, disagreement of RVDD by ≥1 grade was seen in 43 (53.1%) patients and by 2 grades in eight (9%)patients when comparing TTE and TEE-MERVIO, yielding a weighted κ of 0.14 (p=0.123). Disagreement by ≥1 grade was observed in 32 (39.5%) patients and by 2 grades in 10 (12.3%) patients when comparing TTE and TEE-DTGRVIO, yielding a weighted κ of 0.3 (p=0.002). Using the BSE Criteria, disagreement of RVDD grades occurred in nine (11.1%) patients when comparing TTE and TEE-MERVIO, yielding an unweighted κ of 0.25 (p=0.295). Disagreement occurred in 12 (14.8%) patients when comparing TTE and TEE-DTGRVIO, yielding an unweighted κ of 0.260 (p=0.187). There was almost perfect agreement between independent raters regarding both TTE- and TEE-derived RVDD grades per the ASE criteria, and substantial to almost perfect agreement per BSE criteria. Bland-Altman analysis of paired data between the TTE- and TEE-measured values of individual 2D and Doppler parameters showed wide limits of agreement. Conclusions This study revealed, at best, only fair agreement between TTE and TEE in grading RVDD. The measured 2D and Doppler echocardiographic parameters showed wide limits of agreement between TTE and TEE. We recommend further researchto develop a TEE-based algorithm for grading RVDD, and to evaluate the prognostic effectiveness of perioperative TEE for predicting adverse clinical outcomes associated with RVDD.

Echocardiographic Measurements in Normal Chinese Adults (EMINCA) II focusing on left ventricular and left atrial size and function by three-dimensional echocardiography.

Current guidelines encourage large studies in a diverse population to establish normal reference ranges for three-dimensional (3D) echocardiography for different ethnic groups. This study was designed to establish the normal values of 3D-left ventricular (LV) and left atrial (LA) volume and function in a nationwide, population-based cohort of healthy Han Chinese adults. A total of 1117 healthy volunteers aged 18-89 years were enrolled from 28 collaborating laboratories in China. Two sets of 3D echocardiographic instruments were used, and full-volume echocardiographic images were recorded and transmitted to a core laboratory for image analysis with a vendor-independent off-line workstation. Finally, 866 volunteers (mean age of 48.4 years, 402 men) were qualified for final analysis. Most parameters exhibited substantial differences between different sex and age groups, even after indexation by body surface area. The normal ranges of 3D-LV and 3D-LA volume and function differed from those recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, presented by the World Alliance Societies of Echocardiography (WASE) study, and from the 2D values in the EMINCA study. The normal reference values of 3D echocardiography-derived LV and LA volume and function were established for the first time in healthy Han Chinese adults. Normal ranges of 3D-LV and 3D-LA echocardiographic measurements stratified with sex, age, and race should be recommended for clinical applications.

Analysis of Transesophageal Echocardiography Appropriateness for Diagnosing Infective Endocarditis: Insights From Two Tertiary-Care Hospitals

BackgroundEchocardiography plays a key role in the diagnosis of infective endocarditis (IE), and recommendations have been published regarding the appropriate use of transesophageal echocardiography (TEE). The objective of this study is to evaluate the utilization of TEE in Regina, Saskatchewan, in the diagnosis of IE. MethodsA retrospective chart review was performed on patients aged ≥ 18 years who received a TEE test for the diagnosis of IE from January 1 to December 31, 2019. The primary outcome included the proportion of TEE uses that complied with the American College of Cardiology Foundation and American Society of Echocardiography (ACCF and ASE) recommendations and the European Society of Cardiology (ESC) recommendations. ResultsA total of 204 admissions involving 188 patients who had TEE performed for the diagnosis of IE occurred within the study period. The mean age was 53.1 ± 17.1 years. Of the 204 TEE uses, 152 (74.5%) were considered appropriate by the ACCF and ASE recommendations. Having at least one predisposing condition (adjusted odds ratio [aOR] 4.30 [95% confidence interval [CI] 2.11-9.04), P < 0.001]) was more likely to be associated with appropriate TEE use, per the ACCF and ASE criteria. Of the 204 TEE uses, only 80 (39.2%) were considered appropriate by the ESC recommendations. Having a history of intravenous drug use (aOR 3.08 [95% CI 1.08-9.27], P = 0.04) and having blood cultures positive for IE-related organisms (aOR 2.31 [95% CI 1.16-4.80], P = 0.02)) were more likely to be associated with appropriate TEE use, per ESC recommendations. ConclusionsThe current study suggests that the use of TEE in the diagnosis of IE demonstrated variable levels of adherence to recommendations published by the ACCF and ASE and by the ESC, with significant discrepancy between the two.

Intraoperative Echocardiography: Guide to Decision-Making.

This review aims to provide a concise overview of key recommendations, with a specific focus on common challenges faced by intraoperative echocardiographers when dealing with frequently encountered valvular pathologies and mechanical circulatory support. It offers valuable insights for medical practitioners in this field. The American Society of Echocardiography (ASE) and the American College of Cardiology/American Heart Association (ACC/AHA) have released updated comprehensive guidelines for the use of transesophageal echocardiography (TEE) for the assessment of cardiac structures and implanted devices to help guide intraoperative decision-making. Transesophageal echocardiography (TEE) is a regularly employed intraoperative diagnostic and monitoring tool, offering various modalities for the rapid evaluation of valvular and aortic pathology, hemodynamic disturbances, and cardiac function. It is particularly valuable in assessing and placing mechanical circulatory support (MCS) devices, providing views often challenging to obtain through transthoracic echocardiography. Additionally, intraoperative TEE can be used for decision-making in patients with valvular disease allowing incorporation of patient-specific and situational factors. Echocardiographers can employ this information in real-time to help guide surgical treatment selection such as repair, replacement, or deferral of intervention.

Assessment of Left Ventricular Hypertrophy Incidence and Antihypertensive Therapy Efficacy in Hypertensive Patients

Objectives: This study aimed to assess the incidence of left ventricular hypertrophy (LVH) in hypertensive individuals in Karachi, Pakistan, and to evaluate the effectiveness of antihypertensive therapy in preventing LVH. Methodology: A total of 200 hypertensive patients were referred from the Cardiac OPD to the Radiology department of Medicare Cardiac and General Hospital, Karachi, for echocardiography. Echocardiographic measurements of cardiac chambers were performed by expert echocardiographers, and left ventricular mass (LVM) was calculated using the formula recommended by the American Society of Echocardiography. Results: Among the hypertensive patients, 100 had uncontrolled blood pressure (≥140/90 mmHg) while 100 had controlled blood pressure (≤130/80 mmHg). The female-to-male ratio was 3:1, with ages ranging from 21 to 80 years. Patients with uncontrolled hypertension exhibited a higher mean body mass index (29 ± 5 kg/m2) and significantly elevated LVM (mean 154 ± 4 g/m2). Angiotensin receptor inhibitors were the most commonly prescribed and effective antihypertensive agents, either as monotherapy or in combination therapy (60%), demonstrating utility in preventing LVH. Conclusion: This study highlights a high incidence of LVH in uncontrolled hypertensive individuals compared to those with controlled hypertension. Transthoracic echocardiography emerged as a highly valuable, non-invasive tool for measuring LVM and assessing the effectiveness of antihypertensive therapy.

Correlations of Serum Lipid Parameters and Atherogenic Indices With Left Ventricular Diastolic Dysfunction Among Apparently Healthy Patients With Type 2 Diabetes Mellitus: A Multicenter In-Hospital Cross-Sectional Study.

Background: In adolescents with Type 1 diabetes, lipid ratios are predictors of left ventricular diastolic dysfunction (LVDD). However, whether this also applies to adults with Type 2 Diabetes Mellitus (T2DM) is unclear. This study is aimed at assessing the correlations of serum lipid parameters and atherogenic indices with LVDD in patients with T2DM. Methods: This cross-sectional study included 203 patients with T2DM aged 59.9 ± 13.6 years (111 males, sex ratio: 1 : 2 in favor of males) from eight randomly selected urban hospitals. Demographic information was collected, an anthropometric assessment was performed, and blood pressure was measured. Fasting blood samples were obtained to assess total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), glucose, and glycated hemoglobin. The atherogenic index of plasma (AIP), Castelli Risk Index I (CRI-I), Castelli Risk Index II (CRI-II), atherogenic coefficient, and non-HDL-C were determined using specific formulas. Diastolic function was assessed using echocardiography as per the 2016 updated guidelines of the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI). Results: Approximately 47.8% of the participants had LVDD. Compared with participants with normal diastolic function, those with LVDD were more likely to be older than 55 years (p < 0.001), tended to have obesity (p = 0.045), had a higher risk of developing dyslipidemia (p = 0.041), and higher AIP and CRI-II (p < 0.05) levels while having similar low HDL-C and hypertriglyceridemia frequencies. In the multivariate model adjusting for age, high AIP (adjusted odds ratio [aOR], 3.37; 95% confidence interval [CI], 1.22-5.34) and high CRI-II (aOR: 3.80; 95% CI: 2.25-6.35) were independent determinants of LVDD. Conclusions: These results highlight the importance of considering atherogenic indices, primarily AIP and CRI-II in the management of T2DM patients. High AIP and high CRI-II could serve as surrogate markers of LVDD, an early cardiovascular manifestation in patients with T2DM.

Multimodality Imaging for Cardiac Surveillance of Cancer Treatment in Children: Recommendations From the American Society of Echocardiography.

Multimodality Imaging for Cardiac Surveillance of Cancer Treatment in Children: Recommendations From the American Society of Echocardiography.

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

Contribution of the left atrial speckle tracking in the evaluation of left ventricule filling pressure in acute coronary syndromes

Abstract Introduction A non invasive estimation of diastolic function with echocardiography according to consensual methods, ie American society of Echocardiography (ASE) / European association of cardiovascular imaging (EACVI) algorithm 2018, is considered an integral essential part of the clinical evaluation of patients presenting with symptoms of acute coronary syndrome (ACS). Left atrial (LA) longitudinal strain in the frame of speckle tracking echocardiography (STE) was reported recently to have additive diagnostic value to assess left ventricle (LV) filling pressures (LVFP) in a large spectrum of cardiovascular diseases. Our study aim is to assess the accuracy of LA strain in evaluating LVFP in patients with ACS, as a single parameter. Methods Our study was monocentric in our cardiology department led prospectively between April 20, 2022, and June 30, 2022. We included all patients admitted to our department for evolving ST elevation (STEMI) or non-ST elevation (NSTEMI) myocardial infarction (&amp;lt;48 hours from onset of symptoms). Echocardiographic measurements were performed according to ASE/EACVI in less than 24 hours. They were divided into two groups according to the elevation of LVFP group 1 with non-elevated LVFP vs group with elevated LVF. LA-GS was assessed using images obtained in apical 4- and 2-chamber views , with attention to optimal visualization of the LA. The endocardial border of the LA was traced manually. Left atrial reservoir strain (LARS) was calculated from LV-end diastole, and pump strain (LAPS) after the onset of the p-wave in the electrocardiogram. Results Fifty patients were included in our study. The mean age was 59 ± 12 years. 72%(36) of our population was men. 34%(17) of the population had elevated LVFP (Group2) with a male predominance of 82% (14). They were active smokers in 64% (11), 52%(9) had hypertension, 70% (12) had diabetes mellitus, 47%(8) had dyslipidemia and 35% (6) were hospitalized for NSTEMI. The mean LARS and LAPS were 26.9%, and 15.2% in group 1 vs 15.1%, and 7.1% respectively in group 2 with a difference statically significative p = 0.001, and p = 0.002 respectively. The area under the curve was 0.910 (LARS) and 0.850 (LAPS). The best cut-off for the LAPS was 11.5% with 100% of sensibility and 63% of specificity, for the LARS the best cut-off was 18% with 95% of sensibility and 66% of specificity. Conclusion LA-GS includes a reproducible and simple method for LVFP assessment in ACS. it provides an additional variable that can contribute when one of the other parameters is missing.

A preliminary study on the standard value of left ventricular mechanic dyssynchrony by speckle tracking

Abstract Background Speckle tracking imaging automatic functional imaging (AFI) is a new method to measure left ventricular mechanical dyssynchrony. Parameter peak strain dispersion (PSD) is the standard deviation when the long axial strain of 17 segments of the left ventricle (LV) reach there’s peak. There is no unified standard value at present. Li C[1] included 59 healthy women aged 43.08 ± 8.22 years old, whose PSD was 31.44±3.83ms. Ji X[2] included 57 healthy volunteers aged 43.30 ±6.03 years old whose PSD value was 23.8±2.2ms. Some studies referred to the standard range of Yu index and used PSD&amp;gt;32.6ms as an indicator of left ventricular mechanic dyssynchrony. Purpose To investigate the standard value range of PSD and PSD/R-R interval. Methods Healthy volunteers who came to our hospital for physical examination from March 2020 to September 2021 were included, excluding hypertension, diabetes, hyperlipidemia, coronary heart disease and other diseases. According to the 20∼29 years old, 30∼39 years old, 40∼49 years old, 50∼59 years old, 60∼69 years old and 70∼79 years old, 10 males and 10 females were included, respectively. GE Vivid E95 was used to collect echocardiographic images, and the following parameters were measured: ①The general parameters of the heart, such as the diameter of the atrium(LA) and the left ventricle (LV) and the thickness of the left ventricular wall .; ②the values of PSD and PSD/ R-R interval. The normal distribution parameters were represented by mean plus or minus the standard deviation. Analysis of variance and post hoc test (LSDt-test) were used to analyse measured values statistically. Results Values of general echocardiographic data such as BSA, atrial and ventricular diameter, interventricular septal thickness, left ventricular posterior wall thickness, and LV ejection fraction were consistent with the guideline of Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging published in 2015. The range of PSD values for subjects in this study was 43±9ms, and the maximum was 65ms. The range of PSD/R-R was 5±1%, and the maximum was 7%. The values of PSD and PSD/R-R were 36±5ms(27∼45ms) and 4.4±0.76%(3∼6.4%) for 20∼39 years old, 42±5ms(34.9-54ms), 5.0±0.8%(3.5-6.7%) in 40∼59 years; 51±8ms(34∼65ms), 5.8±0.9%(3.9∼7%) in age 60∼79. Conclusions The preliminary study has shown that left ventricular mechanical dyssynchrony is associated with age. The standard value range of PSD is inconsistent in different age groups, and PSD and PSD/R-R values increase with age.PSD values at different agesBar chart of PSD values at different age

Increasing left ventricular mass and mortality in 303,548 men and women investigated with echocardiography

Abstract Background and Aims Left ventricular hypertrophy (LVH) categories are based on left ventricular mass index (LVMi). This study aimed to generate sex-stratified, statistically-derived thresholds of mortality according to LVMi within a large, real-world patient cohort. Methods and Results Echocardiographic and linked mortality data were extracted from the National Echocardiography Database of Australia. LVH categories were first defined according to American Society of Echocardiography (ASE) criteria in 303,548 adults comprising 155,668 men (aged 61.3±17.3 years) and 147,880 women (61.8±18.3 years). Sex-specific mild to severe thresholds of increasing 5-year mortality based on LVMi increments were generated. Overall, 36,198 men (23.3%) and 38,898 women (26.3%) had LVH. Actual 5-year mortality rose from 16.9%-38.3% and 11.9%-31.2% in men and women with no LVH versus LVH, respectively. The statistical threshold at which LVMi was associated with increased mortality was lower than traditional LVH criteria in both men (Figure A, ≥88g/m2 versus ≥115g/m2) and women (Figure B, ≥82g/m2 versus ≥95g/m2). For men versus lowest-risk LVMi, the fully adjusted risk of 5-year mortality was 14% (95%CI 1.03-1.25) and 68% higher (95%CI 1.49-1.90) when LVMi levels were mildly (88 to &amp;lt;116) to severely (≥140g/m2) increased, respectively. In women, the equivalent LVMi thresholds of 82 to &amp;lt;112 and ≥140g/m2 were associated with a 13% (95%CI 1.03-1.24), and 81% higher (95%CI 1.58-2.08) 5-year mortality risk. Conclusion A high proportion of men and women have LVMi levels associated with elevated mortality risk that are lower than those traditionally used to diagnose or manage LVH. Such individuals may benefit from more proactive recognition and clinical management.

Abstract 18420: Appropriateness and Cost Analysis of Adult Inpatient Transthoracic Echocardiograms in a Community Hospital

Introduction: Although inpatient transthoracic echocardiograms (TTEs) are important for guiding patient management, their overuse could be a concern leading to delayed discharges, unnecessary burden on hospital staff, and increased hospital costs. We analyzed the appropriateness, benefits, cost expenditure and unnecessary burden of TTE testing. Methods: A retrospective cohort analysis of a subset of patients undergoing TTEs in 2022 from a community hospital was performed. Appropriateness of use criteria (AUC) in accordance with American Society of Echocardiography and alteration in medical management was evaluated by 3 independent reviewers. Hospital cost analysis was performed based on median TTE cost ($682), yearly total adult TTEs performed (n=4,636), AUC criteria, and alteration in management under Maryland all-payer insurance model. Results: In 234 TTEs matched by age, gender, and race, AUC was not met in 32.5% of patients. Most TTEs were indicated for LV function assessment and ACS (Figure). Change in management was significantly higher in patients who met vs. not meeting AUC (54 vs. 11%, p&lt;0.001). In patients meeting AUC, men had a higher change in management compared to women (61 vs. 46%, p = 0.05). No significant differences were found in the percentage of patients who benefitted from inpatient TTE by subgroups based on indications, except for cardiac trauma. Inappropriate TTE testing led to a yearly loss of approximately $313,000 in hospital revenue and an additional loss of $150,000/year for every 5% of patients who meet AUC with no alteration in medical management. Conclusion: In this community hospital analysis, nearly one-third of adult inpatient TTEs were obtained outside the recommendations of established guidelines. Strategies to improve adherence to ASE guidelines and patient selection for TTE testing are warranted to reduce unnecessary resource utilization and healthcare costs.

Diastolic dysfunction is associated with cardiac decompensation after transjugular intrahepatic portosystemic shunt in patients with liver cirrhosis.

About 20% of patients develop cardiac decompensation within the first year after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for cardiac decompensation remain poorly defined. We aimed to evaluate predictors of cardiac decompensation after TIPS insertion in a large, well-defined cohort of patients with liver cirrhosis. 234 cirrhotic patients who received a TIPS at Hannover Medical School were retrospectively followed up for one year to assess the incidence of cardiac decompensation. Echocardiographic parameters and established diagnostic criteria for cardiac impairment (e.g. by the American Society of Echocardiography/ European Association of Cardiovascular Imaging (ASE/EACVI)) were investigated for an association with cardiac decompensation in a competing risk analysis. Survival was analyzed using a multivariable cox regression analysis adjusting for Freiburg index of post-TIPS survival. Predominant TIPS indication was ascites (83%). Median age was 59years, median MELD-score 12% and 58% were male. Overall, 41 patients (18%) developed cardiac decompensation within one year after TIPS insertion. Diastolic dysfunction according to the ASE/EACVI was diagnosed in 26% of patients at baseline and was linked to a significantly higher risk for cardiac decompensation (p=0.025) after TIPS. When investigating individual echocardiographic baseline parameters, only pathological E/A (<0.8 or >2) was identified as a risk factor for cardiac decompensation (p=0.015). Mortality and liver transplantation (n=50) were significantly higher among patients who developed cardiac decompensation (HR=5.29, p<0.001) as well as in patients with a pathological E/A (HR=2.34, p=0.006). Cardiac high-risk status (44% of patients) was strongly linked to cardiac decompensation (HR=2.93, p=0.002) and mortality (HR=2.24, p=0.012). Cardiac decompensation after TIPS is a frequent and important complication and is associated with reduced survival. American Society of Echocardiography/EACVI criteria and E/A seem to be the best parameters to predict the cardiac risk in cirrhotic patients undergoing TIPS insertion.

Impact of Advanced Cardiac Sonographers on Exam Completeness in the Echocardiography Laboratory

Objective: Laboratory accreditation has been shown to impact variability and completeness. However, little data exist demonstrating the impact of personnel credentialing on completeness and efficiency. Therefore, the aim of this study was to evaluate exam completeness and efficiency among staff with an advanced cardiac sonographer (ACS) credential, Registered Diagnostic Cardiac Sonographer or Registered Cardiac Sonographer and noncredentialed staff. Materials and Methods: Retrospective review of adult and pediatric echocardiograms at eight facilities in three states. Exam completeness was compared with Intersocietal Accreditation Commission (IAC) standards and completeness by pathology was compared with the American Society of Echocardiography (ASE) standards. Results: This study was based on the review of 1147 patient cases. Of the cases reviewed, 60.3% were performed by credentialed (non-ACS) sonographers, 28.3% were completed by credentialed ACS, and 11.3% by noncredentialed staff. The credentialed staff completed exams ≤ 12 hours. The exams were reviewed for compliance with IAC standards and completed by ACS staff: 80.0% in aortic stenosis and 55.6% in non-ACS staff. Those patient cases for mitral regurgitation (14/19) were 73.7% IAC compliant, cases completed by credentialed non-ACS (20/56) were 35.7% compliant, and those completed by noncredentialed sonographers (2/11) only 18.2% were compliant. Cases specific to patent ductus arteriosus were 92.1% compliant with IAC standards that were completed by ACS compared with 77.9% completed by non-ACS staff. Cases of pulmonary hypertension were also evaluated for IAC compliance and 61.8% met the standard with ASE versus 41.7% completed by non-ACS. Conclusion: Examinations performed by ACS are more often complete in important pathology. Examination efficiency is highest among credentialed sonographers.

Prognostic Significance of Diastolic Dysfunction in Type 2 Diabetes Mellitus Patients With Sepsis and Septic Shock: Insights From a Longitudinal Tertiary Care Study.

Sepsis is one of the leading contributors to global mortality and morbidity, causing multi-organ failure, mainly involving cardiovascular failure, both systolic and diastolic dysfunction, leading to adverse clinical outcomes. There is little clinical data on the correlation with the mortality ofpatients with type 2 diabetes mellitus (T2DM) with sepsis and septic shock and left ventricular diastolic dysfunction. Our study sought to assess whether the severity of diastolic dysfunction could predict 28-day mortality. The study included T2DM patients admitted to the intensive care unit (ICU) with sepsisand septic shock defined according to the Third International Consensus Definitions for Sepsis and Septic Shock at a tertiary care center in northern India. A total of 132 patients (age = 61.01 ± 13.12 years; 62% male; mean APACHE II (Acute Physiology and Chronic Health Evaluation II) score = 25.74 ± 4.79; Sequential Organ Failure Assessment (SOFA) score = 12.34 ± 3.36) underwent transthoracic echocardiography within two hours of ICU admission till 28 days of admission or till mortality occurred. Clinical variables (APACHE II and SOFA score) and cardiac biomarkers, such as N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), troponin I, and creatine phosphokinase-MB, were measured at the time of admission and after 72 hours to compare with mortality. Diastolic dysfunction was defined according to the American Society of Echocardiography (ASE) 2009 guidelines, classifying subjects into grade 0 (normal), if early diastolic velocity (e') ≥ 8 cm/s; grade 1 (impaired relaxation), if e' < 8 cm/s and early (E) to late (A) ventricular filling velocities (E/A) ratio < 0.8; grade 2 (pseudo normal), if e' < 8 cm/s, E/A = 0.8-1.5, and peak E-wave velocity by the peak e' velocity (E/e') ratio = 9-12; and grade 3 (restrictive), if e' < 8 cm/s, E/A > 2, deceleration time (DT) < 160 ms, and E/e' ≥ 13. Thirty-seven (40.65%) out of 132 patients had diastolic dysfunction on initial echocardiography, while 54 (59.34%) had diastolic dysfunction on at least subsequent echocardiography. Total mortality was 68.93% with the highest mortality (100%) observed among those with grade 3 diastolic dysfunction. The 28-day mortality with diastolic dysfunction in sepsis and septic shock patients showed significant results (p < 0.001), indicating that with a higherE/A ratio or higher grade of diastolic dysfunction with the increase in SOFA score, the early ICU mortality is the highest and have the shortest duration of ICU stay with mean ± SD = 6.2 ± 2.48, as compared to other grades with 100% mortality. Also, the cardiac biomarkerNT-pro-BNP was markedly elevated with a mean ± SD value of 503 ± 269.3 pg/ml, indicating early predicted mortality.No correlation was detected between mortality and the mean levels of fasting blood sugar, postprandial blood sugar, and glycosylated hemoglobin. Our study concluded that diastolic dysfunction is an important and strongest independent mortality predictor in patients with T2DM with severe sepsis and septic shock, and the higher the grade of diastolic dysfunction, the higher the mortality with the lowest mean ICU stay.