Apical 4-chamber View Research Articles

Passive leg raising test to predict fluid responsiveness using the right ventricle outflow tract velocity-time integral through a subcostal view.

The passive leg raising test (PLR) produces a reversible increase in venous return and, if the patient's ventricles are preload dependent, in the cardiac output. As this effect occurs in seconds, the transthoracic echocardiography is optimal for its real time assessment. The utility of the PLR for monitoring fluid responsiveness through the measurement of the left ventricle outflow tract velocity-time integral (LVOT VTI) in an apical 5-chamber view is well stablished. To achieve this view in critically ill patients is often challenging. The aim of this study is to explore the accuracy for predicting fluid responsiveness of the change in the right ventricle outflow tract velocity-time integral (RVOT VTI) from a subcostal view during a PLR. This is a diagnostic accuracy study carried out in two centers in Argentina. We included patients admitted to the intensive care unit from January 2022 to April 2022, that required fluid expansion due to signs of tissular hypoperfusion. We measured the RVOT VTI from a subcostal view in a semi-recumbent position and during the PLR, and the LVOT VTI in an apical 5-chamber view before and after a fluid bolus. If the LVOT VTI increased by 15% after the fluid bolus, the patients were considered fluid responders. We included 43 patients. The area under the ROC curve for a change in the RVOT VTI during the PLR was 0.879 (95% CI 0.744-0.959). A change of 15.36% in the RVOT VTI with the PLR predicted fluid responsiveness with a sensitivity of 85.7% (95% CI 57.2%-98.2%) and specificity of 93.1% (95% CI 77.2-99.2). The positive predictive value was 85.7% (95% CI 60.8%-95.9%) and the negative predictive value was 93.1% (95% CI 78.8%-98%). The positive likelihood ratio was 12.43 and the negative predictive value was 0.15. The RVOT VTI change during a PLR is suitable for the prediction of fluid responsiveness in critically ill patients.

Man With Chest Tightness and Weight Loss

A 68-year–old man with gastroesophageal reflux disease presented with chest tightness to the emergency department. He had undergone weight loss of 10 kg in the past 3 months. Physical examination revealed normal blood pressure, heart rate and temperature, but a wizened face and fine, brittle hair. Basic blood chemistry tests, chest radiograph, and ECG were unremarkable. Point-of-care ultrasonography with a modified apical 2-chamber view, 90 degrees counterclockwise from the apical 4-chamber position, revealed a dilated tube-like structure between the heart and descending aorta (Figure 1 and Video).

The impact of transcatheter edge-to-edge repair on right ventricle-pulmonary artery coupling in patients with functional mitral regurgitation.

The impact of transcatheter edge-to-edge repair on right ventricle-pulmonary artery coupling in patients with functional mitral regurgitation.

Echocardiography Provides a Reliable Estimate of Total Cardiac Volume for Pediatric Heart Transplantation

Donor-to-recipient size matching for heart transplantation typically involves comparing donor and recipient body weight; however, weight is not linearly related to cardiac size. Attention has shifted toward the use of computed tomography- (CT-) derived total cardiac volume (TCV), that is, CT-TCV, to compare donor and recipient heart organ size. At this time, TCV size matching is near impossible for most centers due to logistical limitations. To overcome this impediment, echocardiogram-derived TCV (ECHO-TCV) is an attractive, alternative option to estimate CT-TCV. The goal of this study is to test whether ECHO-TCV is an accurate and reliable surrogate for TCV measurement compared with the gold standard CT-TCV. ECHO-TCV and CT-TCV were measured in a cohort spanning the neonatal to young adult age range with the intention to simulate the pediatric heart transplant donor pool. ECHO-TCV was measured using a modified Simpson's summation-of-discs method from the apical 4-chamber (A4C) view. The gold standard of CT-TCV was measured from CT scans using three-dimensional reconstruction software. The relationship between ECHO-TCV and CT-TCV was evaluated and compared with other anthropometric and image-based markers that may predict CT-TCV. Inter-rater reliability of ECHO-TCV was tested among 4 independent observers. Subanalyses were performed to identify imaging views and timing that enable greater accuracy of ECHO-TCV. Banked imaging data of 136 subjects with both echocardiogram and CT were identified. ECHO-TCV demonstrated a linear relationship to CT-TCV with a Pearson correlation coefficient of r=0.96 (95% CI, 0.95-0.97; P<.0001) and mean absolute percent error of 8.6%. ECHO-TCV correlated most strongly with CT-TCV in the subset of subjects <4years of age (n=33; r=0.98; 95% CI, 0.96-0.99; P<.0001). The single-score intraclass correlation coefficient across all 4 raters is 0.96 (interquartile range, 0.93-0.98). ECHO-TCV measured from a standard A4C view at end diastole with the atria in the plane of view had the strongest correlation to CT-TCV. ECHO-TCV by the A4C view was found to be both an accurate and reliable alternative measurement of CT-TCV and is derived from readily available donor ECHO images. The ECHO-TCV findings in this study make the ECHO method an attractive means of direct donor-to-recipient TCV size matching in pediatric heart transplantation.

Double Interatrial Septum and Patent Foramen Ovale in Woman With Transient Ischemic Attack.

A 47-year-old woman with a history of hypertension presented with symptoms of transient ischemic attack. Her blood pressure was normal. A 12-lead electrocardiogram and a 24-hour Holter monitor revealed sinus rhythm. Transthoracic echocardiograms showed normal left ventricular systolic function (ejection fraction, 66%), mild left ventricular hypertrophy, and a slightly enlarged left atrium. The apical 4-chamber view showed echo-free space between 2 atria in the center of the interatrial septum (IAS) with 2 parallel atrial-septal structures, raising suspicion of a persistent interatrial space (Fig. 1). With the patient in the Valsalva maneuver, we obtained a 2-dimensional transesophageal echocardiogram (TEE) with agitated saline contrast medium, which revealed a small communication from the interatrial space to the right atrium through a patent foramen ovale (PFO) at the midesophageal short-axis level of the aortic valve (Fig. 2). Real-time 3-dimensional TEE revealed a membrane, parallel to the IAS, that created a double IAS and an additional interatrial space (Figs. 3 and 4). No obstruction existed between the left atrial appendage and the normal pulmonary veins, mitral valve, or coronary sinus. A 2-dimensional TEE in color-flow Doppler mode showed flow into the additional chamber from the left atrium across the left-sided IAS. Previous reports suggest that a double IAS can cause emboli,1,2 so we considered our patient to be at high risk and the PFO to be the cause of her neurologic event. Device closure of the PFO was not attempted because of possible complications from catheter-based closure. The patient was prescribed anticoagulation therapy and was discharged from the hospital after a 5-day stay. At the 3-month follow-up visit, she had no neurologic complications; 4 years later, she remained asymptomatic.Double IAS, an extremely rare congenital cardiac anomaly, is characterized by the presence of 2 distinct interatrial septa enclosing an interatrial chamber. The accessory membrane lies parallel to the IAS, and the pulmonary veins continue to communicate freely with the mitral valve and left atrial appendage.2,3 Most patients are asymptomatic unless thromboembolic complications or cardioembolic events occur. Potential causes of double IAS are abnormal or incomplete fusion of the atrial septum primum with the septum secundum, and embryologic left venous valve derived from the embryologic sinus venosus.2,3 There is no preferred treatment or risk stratification for cardiac sources of embolism in double IAS associated with neurologic events. However, monitoring with 3-dimensional TEE is imperative.

DIFFERENT APPROACHES FOR THE ASSESSMENT OF LEFT ATRIAL VOLUME IN A LARGE SAMPLE OF PATIENTS UNDERGOING AN ECHOCARDIOGRAM FOR CARDIOVASCULAR RISK STRATIFICATION

Objective: Left atrial (LA) enlargement (LAE) is associated to an increased risk of cardiovascular complications, and in particular of atrial fibrillation. When LA size is measured by echocardiography, LA volume measurement is preferred over linear measurements. In fact, the strength of the relationship between cardiovascular diseases is stronger for LA volume than for LA linear dimensions. Recently it has been proposed a new method (LAV_e) to estimate LA volume in order to provide a surrogate of biplane LA volume when direct measurement is not available. The aim of our study was to evaluate the correlation between LA volume assessed by the biplane method(LAV_bip) and LA volume estimated by the linear measurements(LAV_e) and to assess the prevalence of LA enlargement in a large sample of patients undergoing an echocardiogram for cardiovascular risk stratification at an ESH excellence centre in Italy. Design and method: 4941 subjects undergoing a diagnostic work-up for arterial hypertension (known or suspect) were analysed. LAV_bip was assessed as by the area-length method using the apical 4-chamber and 2-chamber views and LAV_e was calculated according to the formula: 2.323*(LA parasternal linear diameter2.071). LAV was indexed to height2. Results: Mean age was 56 ± 16 years, BMI 26 ± 5, 43% of subjects had normal weight, 39% overweight, 18% obese, 54% males, 84 % were hypertensives.Mean LAV_bip was 46.2 ± 18.4 and LAV_e was 35.4 ± 11.6 ml. Mean LAV_bip/h2 was 16.2 ± 6.3 and LAV_e/h2 was 12.4 ± 4.1 ml/h2. The correlation coefficients between the two variables were respectively 0.62 and 0.60 (p &lt; 0.0001). Bland &amp; Altman analysis showed a progressive increase in discrepancy between the two measures with increasing LAV_bip. The prevalence of LA enlargement was 32% with the biplane method and 10 % with the elliptical estimation. Conclusions: In a large sample of subjects undergoing a diagnostic work-up for arterial hypertension we observed a possible underestimation of LAV and a lower prevalence of left atrial enlargement when the elliptical approach is used. These results, if confirmed in other populations, suggest that direct measurement of left atrial volume should be preferred, if available.

Feasibility of tissue-tracking mitral annular displacement in single four-chamber view as a simple index of left ventricular longitudinal deformation.

Left ventricular global longitudinal strain (LVGLS) has prognostic value for adverse cardiac events. Application of speckle-tracking technology to mitral annulus provides easy assessment of tissue-tracking mitral annular displacement (TMAD) in apical four-chamber view. The study aimed to examine whether TMAD can be used as a simple index of LV longitudinal deformation in patients with and without preserved ejection fraction (EF). The study population consisted of 95 consecutive subjects. GLS was assessed from three apical views. TMAD was evaluated as the base-to-apex displacement of septal (TMADsep), lateral (TMADlat), and mid-point of annular line (TMADmid) in apical 4-chamber view. The percentage of TMADmid to LV length from the mid-point of mitral annuls to the apex at end-diastole (%TMADmid) was calculated. We compared each TMAD parameter with GLS by linear regression analysis, and analyzed each TMAD parameter by receiver operating characteristic (ROC) curve to detect impaired LV longitudinal deformation (|GLS|< 15.0%). There were good correlations between each TMAD parameter and GLS (TMADsep: r2 = 0.59, p < 0.01. TMADlat: r2 = 0.65, p < 0.01. TMADmid: r2 = 0.68, p < 0.01. %TMADmid: r2 = 0.75, p < 0.01). According to ROC curve, %TMADmid < 10.5% was the best cut-off value in determining impaired LV longitudinal deformation (|GLS|≤ 15.0%) with a sensitivity of 95% and a specificity of 93%. The area under the curve (AUC) of %TMADmid was 0.98 (95%confidence intervals (CI) 0.93-0.99). TMAD using speckle-tracking echocardiography quickly estimated from single apical four-chamber view can be used as a simple index for detection of impaired LV longitudinal deformation in patients with and without preserved EF.

The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation.

Resuscitation guidelines emphasize minimal interruption of compressions during cardiopulmonary resuscitation. Point-of-care ultrasound (POCUS) enables the clinician to visualize cardiac contractility and central artery pulsatility. The apical 4-chamber (A4), subxiphoid (SX), and femoral artery views may be used when defibrillator pads or active compressions preclude parasternal cardiac views. We hypothesized that clinicians can rapidly obtain interpretable POCUS views in healthy children from the A4, SX, and femoral positions. A prospective study of pediatric emergency medicine providers in an urban academic hospital was performed. Stable patients of 12 years or younger were scanned. Sonologists were each allotted 10 seconds to acquire A4, SX, and femoral views. Two attempts at each view were allowed. The primary outcome was whether cardiac and femoral artery scans were interpretable for contractility and pulsatility, respectively. The secondary outcome was whether cardiac scans were interpretable for effusion or right ventricular strain. A POCUS expert reviewed scans to confirm interpretability. Twenty-two sonologists performed a total of 50 scans on 22 patients. A view that was interpretable for contractility was obtained on the first attempt in 86% of A4 and 94% of SX scans. A femoral view that was interpretable for pulsatility was obtained on the first attempt in 74% of scans. Expert review was concordant with sonologist interpretation. Pediatric emergency medicine physicians can obtain interpretable cardiac and central artery views within 10 seconds most of the time. Point-of-care ultrasound has the potential to enhance care during pediatric resuscitation. Future studies on the impact of POCUS pulse checks in actual pediatric resuscitations should be performed.

Differentiation of the Left and Right Side Interventricular Septum Function in Healthy Subjects by Vector Velocity Imaging.

Background: The present study aimed to assess and compare regional strain of the right and left sides of interventricular septum in healthy subjects using velocity vector imaging analysis due to the importance of interventricular septum and limited basic information about the exact function of the interventricular septum.MethodsThe present study was conducted on 40 healthy subjects. Echocardiography was performed in the apical 4-chamber view in the left lateral decubitus position. Image analysis was done offline with velocity vector imaging; the longitudinal strain and strain rate were calculated during 3 cardiac cycles. Strain-time and strain rate-time curves in basal, middle, and apical segments of the left and right sides of interventricular septum were recorded; peak values and time to peak strain were determined. ResultsThere was no significant difference between the longitudinal strain in the right and left basal (−17.7 ± 5.10% vs. −18.2 ± 5.14%, P = .550), middle (−17.1 ± 4.53% vs. −17.9 ± 4.29%, P = .197) segments, strain rate of basal (−1.1 ± 0.36 1/s vs. −1.0 ± 0.36 1/s, P = .350), and middle (−1.0 ± 0.30 1/s vs. −1.1 ± 0.32 1/s, P =0.551) segments. However, there was a significant difference between the longitudinal strain (−22.2 ± 5.55% vs. −16.6 ± 4.45%, P < .001) and strain rate (−1.5 ± 0.46 1/s vs. −1.1 ± 0.33 1/s, P < .001) of the apical segment. Time to peak strain was significantly different only in the middle segment of interventricular septum (right side: 351.0 ±11.5 ms vs.left side: 344.4 ± 13.1 ms, P = .004). ConclusionsThe findings of this study suggest that the right and left function of the septum was comparable in the basal and middle segments of healthy subjects; this function was significantly different in the apical segments.

Assessment of Artificial Intelligence in Echocardiography Diagnostics in Differentiating Takotsubo Syndrome From Myocardial Infarction

Machine learning algorithms enable the automatic classification of cardiovascular diseases based on raw cardiac ultrasound imaging data. However, the utility of machine learning in distinguishing between takotsubo syndrome (TTS) and acute myocardial infarction (AMI) has not been studied. To assess the utility of machine learning systems for automatic discrimination of TTS and AMI. This cohort study included clinical data and transthoracic echocardiogram results of patients with AMI from the Zurich Acute Coronary Syndrome Registry and patients with TTS obtained from 7 cardiovascular centers in the International Takotsubo Registry. Data from the validation cohort were obtained from April 2011 to February 2017. Data from the training cohort were obtained from March 2017 to May 2019. Data were analyzed from September 2019 to June 2021. Transthoracic echocardiograms of 224 patients with TTS and 224 patients with AMI were analyzed. Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity of the machine learning system evaluated on an independent data set and 4 practicing cardiologists for comparison. Echocardiography videos of 228 patients were used in the development and training of a deep learning model. The performance of the automated echocardiogram video analysis method was evaluated on an independent data set consisting of 220 patients. Data were matched according to age, sex, and ST-segment elevation/non-ST-segment elevation (1 patient with AMI for each patient with TTS). Predictions were compared with echocardiographic-based interpretations from 4 practicing cardiologists in terms of sensitivity, specificity, and AUC calculated from confidence scores concerning their binary diagnosis. In this cohort study, apical 2-chamber and 4-chamber echocardiographic views of 110 patients with TTS (mean [SD] age, 68.4 [12.1] years; 103 [90.4%] were female) and 110 patients with AMI (mean [SD] age, 69.1 [12.2] years; 103 [90.4%] were female) from an independent data set were evaluated. This approach achieved a mean (SD) AUC of 0.79 (0.01) with an overall accuracy of 74.8 (0.7%). In comparison, cardiologists achieved a mean (SD) AUC of 0.71 (0.03) and accuracy of 64.4 (3.5%) on the same data set. In a subanalysis based on 61 patients with apical TTS and 56 patients with AMI due to occlusion of the left anterior descending coronary artery, the model achieved a mean (SD) AUC score of 0.84 (0.01) and an accuracy of 78.6 (1.6%), outperforming the 4 practicing cardiologists (mean [SD] AUC, 0.72 [0.02]) and accuracy of 66.9 (2.8%). In this cohort study, a real-time system for fully automated interpretation of echocardiogram videos was established and trained to differentiate TTS from AMI. While this system was more accurate than cardiologists in echocardiography-based disease classification, further studies are warranted for clinical application.

Atrial remodelling comparison after maze-3 and cryo-maze procedures in combined cardiac interventions: a retrospective study

Background. The maze procedure aims to eliminate atrial fibrillation (AF), restore sinus rhythm (SR) and atrial contractility. However, conflicting evidence exists regarding the extent of atrial remodelling in various techniques, which directed the focus of our study.Objectives. An atrial remodelling comparison after a cut-and-sew maze-3 surgery and its biatrial cryo-maze modification using 2D echocardiography.Methods. The study is a retrospective uncontrolled interrupted two-cohort time-series trial, with patients selected by pseudorandomisation according to a normal sinus rhythm-maintaining AF surgery method. A total of 217 maze-3 and 113 cryo-maze combined cardiac interventions have been performed within 2012–2021. The interventions included valve repair, coronary artery bypass grafting and their combination. Due to differences in long-term follow-up, the cohorts were pseudorandomised to select by 50 restored vs. maintained sinus rhythm patients using a nearest-neighbour classifier coupled with logistic regression. Mean follow-up period was 6 (1–17) months. The patients had paroxysmal, persistent and longstanding persistent AF. Echocardiography values prior to and long-term post-surgery were further analysed to determine the atrial remodelling dynamics. Results. A statistically significant atrial volume reduction is evident in a long-term within-cohort comparison. Meanwhile, a statistically more pronounced remodelling is observed between cohorts after maze-3 procedure. The cohort 1 vs. 2 estimates are: mean left atrial volume 120/125 mL3 (p = 0.011), left atrial size in apical view 52/53 mm (p = 0.023), right atrial size in apical view 58/62 mm (p = 0.004), right atrial size in parasternal short axis view 43/45 mm (p = 0.004), right atrial area in apical 4-chamber view 25/28 cm2 (p = 0.007). Maintained atrial pacing patients had positive systolic atrial function recovery rates (E/A ratio increased to average 1.5) in the long-term in both comparison cohorts.Conclusion. Remodelling is biatrial after all the maze procedures compared. A more pronounced atrial volume reduction occurs after maze-3 surgery. The presence of sinus rhythm is facilitated by cardiac conduction leading to mechanical and electrical remodelling of the atria.

Fully automated quantification of cardiac chamber and function assessment in 2-D echocardiography: clinical feasibility of deep learning-based algorithms

We aimed to compare the segmentation performance of the current prominent deep learning (DL) algorithms with ground-truth segmentations and to validate the reproducibility of the manually created 2D echocardiographic four cardiac chamber ground-truth annotation. Recently emerged DL based fully-automated chamber segmentation and function assessment methods have shown great potential for future application in aiding image acquisition, quantification, and suggestion for diagnosis. However, the performance of current DL algorithms have not previously been compared with each other. In addition, the reproducibility of ground-truth annotations which are the basis of these algorithms have not yet been fully validated. We retrospectively enrolled 500 consecutive patients who underwent transthoracic echocardiogram (TTE) from December 2019 to December 2020. Simple U-net, Res-U-net, and Dense-U-net algorithms were compared for the segmentation performances and clinical indices such as left atrial volume (LAV), left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), LV mass, and ejection fraction (EF) were evaluated. The inter- and intra-observer variability analysis was performed by two expert sonographers for a randomly selected echocardiographic view in 100 patients (apical 2-chamber, apical 4-chamber, and parasternal short axis views). The overall performance of all DL methods was excellent [average dice similarity coefficient (DSC) 0.91 to 0.95 and average Intersection over union (IOU) 0.83 to 0.90], with the exception of LV wall area on PSAX view (average DSC of 0.83, IOU 0.72). In addition, there were no significant difference in clinical indices between ground truth and automated DL measurements. For inter- and intra-observer variability analysis, the overall intra observer reproducibility was excellent: LAV (ICC = 0.995), LVEDV (ICC = 0.996), LVESV (ICC = 0.997), LV mass (ICC = 0.991) and EF (ICC = 0.984). The inter-observer reproducibility was slightly lower as compared to intraobserver agreement: LAV (ICC = 0.976), LVEDV (ICC = 0.982), LVESV (ICC = 0.970), LV mass (ICC = 0.971), and EF (ICC = 0.899). The three current prominent DL-based fully automated methods are able to reliably perform four-chamber segmentation and quantification of clinical indices. Furthermore, we were able to validate the four cardiac chamber ground-truth annotation and demonstrate an overall excellent reproducibility, but still with some degree of inter-observer variability.

Assessment of left atrial strain reservoir in patients with ischaemic stroke: a case-control study

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Left atrial (LA) function is considered a seperate marker of cardiovascular disease and its assessment with echocardiography strain analysis has been gaining interest lately. The association of LA characteristics with ischaemic stroke has not been fully understood. Purpose This is a case-control study aiming to identidy differences in LA reservoir strain between ischaemic stroke patients and healthy controls. Methods Consecutive ischaemic stroke patients with preserved left ventricular ejection fraction and sinus rhythm were enrolled in the study. Patients were assessed with 2-dimensional transthoracic echocardiography (apical 4-chamber view) using longitudinal speckle-tracking technique. Non-parametric testing with Mann-Whitney U analysis (new procedure) was carried out to identify differences in the distribution of LA reservoir strain values within the patients group and the controls. A p value of &amp;lt;0.05 was considered statistically significant. Results Sixty-six patients (44 males, 22 females) of a mean age of 49.97 years [minimum = 20, maximum = 61, standard deviation (SD)=8.90] were enrolled in the stroke group. The control group included 39 healthy volunteers (27 males, 12 females) of a mean age of 42.23 years (minimum = 19, maximum = 71, SD = 12.77). In the stroke group, the mean LA reservoir strain was 34.24% (minimum = 5.62, maximum = 71.88%, SD = 10.21%) and the median was 34.06%, whereas the mean and median values of control subjects were 42.84% (minimum = 24.20, maximum = 90, SD = 13.87%) and 39.59% respectively. Mann-Whitneu U analysis (new procedure) showed lower LA strain values in the stroke group (mean rank = 45.29, Mann-Whitney U = 778, p = 0.001) compared to controls (mean rank = 66.05). Conclusion Our study showed that ischaemic stroke patients on sinus rhythm at presentation had impaired LA reservoir strain compared to healthy adults. The role of speckle-tracking echocardiography in assessing LA function and predicting stroke needs to be further evaluated thorougly. Figure Mann-Whitney U testing (new procedure) of left atrial reservoir strain in the stroke group and in healthy controls. Abstract Figure.

Prognostic significance of peak atrial longitudinal strain in patients with functional mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Chronic mitral regurgitation has been shown to promote left atrial (LA) dysfunction and remodeling. However, the significance of LA dysfunction in this setting has not been fully investigated. The aim of our study was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in a cohort of patients with LV systolic dysfunction and functional mitral regurgitation (FMR). Methods Patients with at least mild FMR and reduced LVEF (&amp;lt; 50%) under optimized medical therapy who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single-centre. FMR grading was undertaken according to the new 2021 valvular guidelines. PALS was assessed by 2D speckle tracking in apical 4-chamber view (as per EACVI current recommendations). Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters, namely PALS, and all-cause mortality. Results A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median mitral regurgitant volume was 25mL (IQR: 14 – 34mL). According to the new ESC 2021 valvular guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. Median PALS was 14% (IQR 8 – 20%). The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS (figure 1). On ROC curve analysis, the best PALS cut-off value associated with mortality was &amp;lt; 15%. Kaplan-Meier survival curves according to FMR severity and PALS &amp;gt; or &amp;lt; 15% are depicted in figure 2. PALS remained independently associated with all-cause mortality on multivariable analysis (adjusted hazard ratio [aHR]: 0.94; 95%CI: 0.90 – 0.98; p = 0.004) even after adjustment for several (n = 14) clinical and echocardiographic confounders. Conclusion In a cohort of patients with reduced LVEF and functional mitral regurgitation, peak atrial longitudinal strain was associated with all-cause mortality. Abstract Figure 1 Abstract Figure 2

The effect of urgent blood pressure lowering on left atrial mechanics in patients with hypertensive episode in emergency setting

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial (LA) dilatation and dysfunction are early manifestation of hypertension and represent end-organ damage. Hypertension is a well-known risk factor for atrial fibrillation. Long term effect of hypertension on the left ventricle and left atrium was well-studied before. In this study, we aimed to investigate the acute effect of urgent blood pressure reduction on the left atrial strain. Methods We prospectively enrolled 52 consecutive patients (age: 67.5 ± 8.9 years, 48.1% male) (Fig1) admitted to our emergency department with a hypertensive attack. All patients underwent baseline standard echocardiographic evaluation. 2D images from apical 4-chamber view were recorded for offline analysis. Reservoir (PALS) and contractile (PACS) left atrial strain measurements were performed by automated software using the onset of QRS as a reference point. Patients with systolic dysfunction, acute coronary syndrome and any rhythym other than sinus or with poor echogeneicity were excluded. All measurements were repeated after achieving target blood pressure reduction and analyzed. Results Urgent blood pressure reduction result in improvement in LA contractile strain (PACS) and LVEF and increase in heart rate and RV systolic function while LV dimensions, LA volumes and LAVI were decreased. There is a statistically significant negative moderate relationship between absolute change of DBP and absolute change of PALS (r=-0.423; p = 0.002). There is a statistically significant negative and weak correlation between the absolute change in SBP and the absolute change in PACS (r=-0.280; p = 0.044). Conclusion Assessment of LA strain by 2D speckle tracking echocardiography is easy to apply and noninasive method to quantify LA function even in emergency setting. This study showed that LA contractile strain (PACS) rather than LA reservoir strain (PALS) was significantly affected from LV end diastolic pressure. Abstract Figure 1 Abstract Figure 2

Detection of a diastolic heart sound in children and young adults using high-frame-rate echocardiography

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Colin"s Kids, Inc. PO Box 93 Hopewell, NJ 08525 Introduction The auscultatory finding of a fourth heart sound (S4) is clinically associated with a pathologic decrease in left ventricular compliance, but may be seen in healthy children by phonocardiography. High-frame-rate difference imaging (HFRDI) has demonstrated several propagating myocardial phenomena in the left ventricular (LV) lateral wall throughout the cardiac cycle, including during diastole. We hypothesize that these visualized wave phenomena correlate with physiologic and pathologic heart sounds. Purpose Using HFRDI, we sought to define the characteristics of a LV lateral wall late diastolic wave in healthy children and young adults. Methods HFRDI was obtained from the apical 4-chamber view with synchronized electrocardiogram (ECG) on the T5 system (Phased Array Research Scanner) acquiring images for this study between 587 and 1174 frames per second (depending on participant imaging characteristics). In addition, tissue Doppler images were acquired with synchronized ECG and phonocardiography (PCG) on a commercial ultrasound machine (Figure 1). Timing events were measured from the QRS onset on the ECG tracing. An S4 wave correlate was defined by meeting the following criteria: 1) occurring after the P wave on ECG; 2) at or after the onset of a’ on TDI; 3) occurring during the PCG S4; and 4) occurring prior to the S1 wave complex. The timing of the S4 wave in HFRDI was measured from the onset of QRS to the first appearance of the wave, and the wave velocity was calculated by measuring the length of the lateral wall and counting temporally calibrated image frames while the wave was visible. Results Nine healthy volunteers completed the imaging protocol with a median age of 20 years (range 6 – 22 years). A single, distinct late diastolic HFRDI wave was seen in all participants propagating from apex to base of the lateral LV free wall. This wave met the defined criteria to be a visual correlate of S4 in all participants. Measurements of correlated events are presented in Table 1. S4 propagating velocity was 2.96 ± 1.8 m/sec and occurred 25 ± 18 msec prior to the QRS onset. There is a strong positive correlation between age and S4 velocity [r(7) = 0.76, p = 0.019]. Conclusion The S4 heart sound can be reliably visualized by high frame rate imaging and has similar characteristics in healthy children and young adults. Further definition of normal and abnormal S4 wave characteristics may lead to a novel tool in defining LV diastolic function. Abstract Table 1 Abstract Figure 1

Impaired left atrial reservoir strain in patients with ischaemic stroke is associated with atrial fibrillation development

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction The investigation of patients with ischaemic stroke includes undoubtedly their evaluation for atrial fibrillation (AF). On the other hand, the role of left atrial (LA) function in cardiovascular disease is increasingly researched, while echocardiography strain analysis is a novel attractive technique. Purpose In this retrospective study, we investigated the association between LA function assessed with reservoir strain and the follow-up development of AF. Methods The study population consisted of consecutive ischaemic stroke patients with preserved left ventricular ejection fraction who were on sinus rhythm at the moment of enrollment and had no history of AF. Baseline LA reservoir strain was assessed with 2-dimensional transthoracic echocardiography (apical 4-chamber view) using longitudinal speckle-tracking technique. Afterwards, patients were investigated for AF with ambulatory electrocardiography during one-year follow-up. Differences in the distribution of LA reservoir strain values within the groups of patients with and without AF development were examined with Mann-Whitney U test (new procedure). The level of statistical significance was set to a p value of &amp;lt;0.05. Results Sixty-three patients (41 males, 22 females) of a mean age of 50.94 years [minimum = 20, maximum = 65, standard deviation (SD)=10,02] were enrolled in the study. Eight (12.7%) patients developed atrial fibrillation on follow-up. Overall, the mean LA reservoir strain was 32.75% (minimum = 5.62%, maximum = 71.88%, SD=%) and the median value was 32.91%. The values were shown to be lower in the group with later AF development (mean rank = 13.94, Mann-Whitney U = 75.5, p = 0.003) than in those without this finding (mean rank = 13.94). Neither the gender nor the age was associated with AF diagnosis. Conclusion Lower LA reservoir strain values were found to be associated with AF development in ischaemic stroke patients of our study. Pending more research data from large studies, this novel technique appears to be promising in identifying AF risk in stroke patients. Figure Non parametric assessment with Mann-Whitney U test (new procedure) of left atrial reservoir strain analysis with 2-dimensional transthoracic echocardiography in the groups of ischaemic stroke patients with and without atrial fibrillation development. Abstract Figure.

Five-year follow-up and outcomes of takotsubo/stress cardiomyopathy in a single centre- an irish perspective

Abstract Funding Acknowledgements Type of funding sources: None. Background Takotsubo Cardiomyopathy (TC) is an acute cardiac presentation characterised by acute myocardial injury and transient left ventricular systolic dysfunction, in the absence of obstructive coronary disease(1). Postulated causes include catecholamine excess, microvascular dysfunction, and multi-vessel coronary artery spasm. Predominantly seen in post-menopausal women, frequently triggered by emotional or physical stressor with in-hospital mortality rate reported at 2-5%(2). We present a single centre experience of TC with five-year follow-up. Methods We performed a retrospective descriptive study of patients with a diagnosis of TC coded by Hospital In-Patient Enquiry data from a tertiary level Irish hospital between 2010 and 2016. Data collection was electronic patient records/chart review. 21 cases were confirmed by modified Mayo Clinic criteria(3). Three patients were lost to follow up, two patients died during the follow-up period and one patient was excluded due to a focal area of transmural infarction on follow-up cardiac magnetic-resonance imaging (CMRI). Follow up data was obtained on sixteen patients up to 01/08/2021. Statistical analysis using SPSS v. 27, expressed as mean +- SD in %. Results Mean age at event was 64 +/- 12 years, 95% were female. Triggers identified in 55% of cases; emotional stressors in 35%, physical stressors in 25%. All had raised Troponin I (peak 3.13 ± 2.42ng/ml) and electrocardiograph (ECG) changes. Coronary angiography performed in all with no or mild CAD in seventeen and moderate CAD in two cases. CMRI was performed in 60% (n = 12) at on average 14.8 months post discharge. Average left ventricular ejection fraction (LVEF) was 31+/- 8% and 62+/-7% at diagnosis and follow up respectively, improving in all cases with mean improvement of 30.8 +/-11% (p &amp;lt; 0.001). Three patients had a further TC event. Two of the cases underwent angiography at the time of second presentation with normal coronary arteries and follow-up imaging showed full LVEF recovery in both cases. The third patient is awaiting follow-up CMRI. Of the recurrent cases two occurred despite best medical therapy. Two of the cases showed full recovery of LVEF between events and one showed minimal LVEF improvement prior to recurrence but full recovery after the second event. All patients who remained in Ireland had initial follow up (n = 15), 46% attend Cardiology outpatients in 2021. Conclusions Our demographic data is similar to previous studies with the majority of cases occurring in postmenopausal women(4). Our mortality rate was 9.5%, current published prognostic data in TC are limited and conflicting(2). The recurrence rate among our small cohort was 16.6% (n = 3) despite cardio-protective medications in two of the three cases, higher than previous reviews(5). The time to clinical and imaging follow up was discordant but all patients in our follow up group regained a normal LVEF which is very reassuring and in-keeping with prior studies. Abstract Figure. TTE apical 4-chamber view Abstract Figure. CMRI 4-chamber view end systole

Variability of right ventricular linear measurements of size and function using a standardized echocardiographic protocol

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular size and function have a prognostic value not only in right heart conditions (pulmonary hypertension, congenital heart disease), but also in left ventricular (LV) disease states. The right ventricle (RV) has a unique shape, for which a simple geometrical model is not achievable as is the case for the LV. In clinical practice simple measurements are used for the RV, since these are considered to be most reliable and reproducible: linear cavity dimensions, tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler systolic velocity s’ at the tricuspid annulus. The latest RV quantitation guidelines made important modifications to RV measurements, in particular, by shifting from the apical 4-chamber view to the RV focused apical view. Very scarce data exist on the variability of these measurements. Purpose In this study we aim to analyze the intra and inter-observer variability of the linear measurements of RV size and function using a standardized methodology. Methods A mixed cohort, randomly selected from the echocardiographic database, comprising 50 patients, was retrospectively analyzed. We measured linear diameters (basal = 1, longitudinal = 2, mid = 3) in apical RV-focused view, TAPSE and s’. Based on computer simulations, we propose a step-by-step approach: tracing the longitudinal diameter as perpendicular to the mid of the basal and generally parallel with the interventricular septum, and the mid as perpendicular to the middle of the longitudinal (Figure). Two observers measured independently the same images at baseline, three (inter-observer) and six months (intra-observer). Results The longitudinal diameter had the lowest relative bias (3% inter and 4% intra-observer), followed by the basal (7% and 2%), and mid (6% and 6%). The limits of agreement (LOA) were small for s’ (-3 to 1 intra and -1 to 1mm inter-observer), TAPSE (-6 to 5 and -3 to 3mm), and larger for diameters (1=-5 to 10 and -8 to 6; 2=-13 to 17 and -11 to 6; 3=-11 to 7 and -9 to 4mm). ICCs for individual measurements were very good (1= 0.94 intra and 0.94 inter; 2 = 0.78 and 0.94; 3: 0.72 and 0.56; TAPSE: 0.86 and 0.94; s’=0.94 and 0.98), p &amp;lt; 0.001 for all (Table). Conclusion A systematic approach to linear RV-focused apical view measurements may lead to reproducible results. It is essential that size measurements be performed in the RV focused view. Our study shows best consistency and reproducibility for the basal diameter and the linear functional parameters. Echocardiographic laboratories may benefit from implementing a consistent analysis protocol and assessing its reproducibility. Abstract Figure: linear RV measurements Abstract Table: variability results

Negative prognostic impact of right ventricular free wall strain in patients with functional mitral regurgitation undergoing transcatheter edge-to-edge repair

Abstract Funding Acknowledgements Type of funding sources: None. Backgrounds although right ventricular (RV) systolic dysfunction seems to be associated with adverse outcome after transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system, the prognostic value of RV free wall strain in this setting has not been yet investigated. Purpose aim of this study is to evaluate RV free wall strain as predictor of outcome in patients with severe or moderate-to-severe functional MR undergoing TEER and its prognostic role compared with tricuspid annular plane systolic excursion (TAPSE). Methods 102 patients [73 (IQR 66.8-77.0) years, 73 males (71.6%)] were retrospectively selected from March 2012 to February 2021. Echocardiograms were performed by using General Electric machines. RV free wall strain was assessed through RV modified apical 4-chamber view, setting the region of interest to minimum size (Figure 1). Values of RV free wall strain &amp;gt;-20% were recognized as abnormal. We considered a composite endpoint including rehospitalization for heart failure (HF) and overall death as primary outcome. Secondary outcomes were overall death, cardiac death and rehospitalization for HF. All patients were assessed at the longest available follow-up [median 22.1 (IQR 9.7-49.3) months]. Results primary outcome was found in 60 (58.8%) patients, while secondary outcomes, i.e. overall death, cardiac death and rehospitalization for HF, were found respectively in 50 (50.0%), 31 (30.4%) and 36 (35.3%) patients. Mean TAPSE was 16.7 ± 4.0 mm and mean RV free wall strain was -16.9 ± 6.0%. At univariable analysis both TAPSE (HR 0.907, CI 0.848-0.970, p value 0.004) and RV free wall strain (HR 0.937, CI 0.897-0.979, p value 0.004) were significantly associated with the primary outcome. Kaplan-Meier survival curves showed that patients with TAPSE &amp;lt;17 mm had a lower survival free from the composite outcome compared with those with TAPSE ≥17 mm (Log-Rank = 0.030); patients with RV free wall strain value &amp;gt; -20% also showed a lower survival free from the composite outcome compared with patients with RV free wall strain ≤-20% (Log Rank 0.004). Among patients with preserved RV systolic longitudinal function as indicated by TAPSE ≥17 mm, subjects with RV free wall strain &amp;gt;-20% had a significantly higher incidence of the composite outcome compare with those with RV free wall strain ≤-20% (Log-Rank = 0.008, Figure 2). Conversely, no difference was found among patients with TAPSE &amp;lt;17 mm. Conclusions RV dysfunction assessed either by TAPSE and RV free wall strain is associated with poorer outcome in patients with severe or moderate-to-severe functional MR undergoing TEER. Compared with TAPSE, RV free wall strain seems to be superior in identifying patients at higher risk of adverse events during follow-up. Our data encourage the use of this speckle tracking-derived echocardiographic parameter in routinely evaluation of patients with functional MR candidate for TEER. Abstract Figure. Abstract Figure 2