Apical Four-chamber View Research Articles

What we believed to be a right upper pulmonary vein by transthoracic echocardiography is actually a right lower pulmonary vein.

Current guidelines recommend that pulmonary vein (PV) velocity should be recorded by using the right upper pulmonary vein (RUPV) during transthoracic echocardiography (TTE) evaluation of left ventricular diastolic function. However, it is uncertain whether the PV displayed during TTE is truly measuring the upper PV. This study aimed to identify the actual site of each PV that is usually detected during TTE. We retrospectively studied 105 patients who underwent cardiac computed tomography (CT) and TTE, reconstructed images three-dimensionally, and measured the angles between each PV and the left ventricle (LV) that would correspond to the Doppler incident angle of the apical four-chamber view on TTE. We also performed TTE during catheter ablation to confirm the exact site of the PV. Apical four-chamber views on TTE revealed that one certain PV was detectable on the right side of the vertebra. CT scans revealed that the median angle of the axes between the LV and right lower pulmonary vein (RLPV) was smaller than that of RUPV {32.1˚ [interquartile range (IQR): 21.7˚-42.1˚] vs. 62.5˚ (IQR: 51.6˚-70.6˚), P<.001}. During catheter ablation for treatment of atrial fibrillation, in the most well-displayed PV on TTE, we detected the ablation catheter placed in the RLPV. The most well-displayed PV in an apical four-chamber view by TTE was not the RUPV but the RLPV which showed the smallest angle of incidence toward the LV apex. The RLPV is suitable for evaluation of PV velocity to assess LV diastolic function.

Biventricular Longitudinal Strain Predict Mortality in COVID-19 Patients.

Background: Biventricular longitudinal strain has been recently demonstrated to be predictive of poor outcomes in various cardiovascular settings. Therefore, this study sought to investigate the prognostic implications of biventricular longitudinal strain in patients with coronavirus disease 2019 (COVID-19).Methods: We enrolled 132 consecutive patients with COVID-19. Left ventricular global longitudinal strain from the apical four-chamber views (LV GLS4CH) and right ventricular free wall longitudinal strain (RV FWLS) were obtained using two-dimensional speckle-tracking echocardiography.Results: Compared with patients without cardiac injury, those with cardiac injury had higher levels of coagulopathy and inflammatory biomarkers, higher incidence of complications, more mechanical ventilation therapy, and higher mortality. Patients with cardiac injury displayed decreased LV GLS4CH and RV FWLS, elevated pulmonary artery systolic pressure, and higher proportion of pericardial effusion. Higher biomarkers levels of inflammation and cardiac injury, and the presence of pericardial effusion were correlated with decreases in LV GLS4CH and RV FWLS. During hospitalization, 19 patients died. Compared with survivors, LV GLS4CH and RV FWLS were impaired in non-survivors. At a 3-month follow-up after discharge, significant improvements were observed in LV GLS4CH and RV FWLS. Multivariate Cox analysis revealed that LV GLS4CH [hazard ratio: 1.41; 95% confidence interval [CI]: 1.08 to 1.84; P = 0.011] and RV FWLS (HR: 1.29; 95% CI: 1.09–1.52; P = 0.003) were independent predictors of higher mortality in patients with COVID-19.Conclusions: LV GLS4CH and RV FWLS are independent and strong predictors of higher mortality in COVID-19 patients and can track improvement during the convalescent phase of their illness. Therefore, biventricular longitudinal strain may be crucial for risk stratification and serial follow-up in patients with COVID-19.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87–0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: –0.61%, 95% confidence interval: –1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

TRICUSPID VALVE REGURGITATION IN PATIENTS UNDERGOING ENDOCARDIAL LEADS PLACEMENT

Objective: To assess prospectively the presence and degree of tricuspid regurgitation (TR) after right ventricular (RV) lead placement utilizing 2-dimensional and doppler echocardiography in a group of patients implanted with Permanent pace-maker or implantable cardioverter defibrillator (ICD).&#x0D; Study Design: Descriptive cross sectional study.&#x0D; Place and Duration of Study: Study was conducted at OPD of AFIC/NIHD Rawalpindi from Jan to Jun 2019.&#x0D; Methodology: One hundred patients after cardiac stimulation system implantation were included in this study. Patients with severe valve disease, heart failure, congenital heart disease, pre-existing pulmonary hypertension and presence of moderate or severe tricuspid regurgitation were excluded. M-mode, 2 –dimensional and doppler echocardiographic studies were performed. Continuous-wave doppler measurements were made from apical four-chamber view in order to obtain maximum tricuspid flow velocities. A complete echocardiographic study was performed following device implantation. Echocardiographic measurements were repeated at 6-months of follow-up period. Those patients who developed tricuspid regurgitation were further assessed by color doppler, taking into account density and contour of the jet on continuous-wave doppler. Tricuspid regurgitation severity was classified into three groups: mild, moderate and severe according to the recommendations for non-invasive evaluation of native valvular regurgitation by the American Society of Echocardiography. The collected data was analysed by using SPSS-23.&#x0D; Results: Out of 100 patients, 67 (67%) were males and 33(33%) were females with the mean age of 65.29 ± 12.02 years. All the patients had normal chambers dimensions before the procedure. 65 (65%) had leads screwed to RV apex while 35 (35%) had through RV septum. 83 (83%) patients received a dual chamber device, while 17 (17%) patients got single chamber (ventricular) device implanted. Following device implantation after 6 months mild TR was noted in 4 (4%), moderate TR in 4 (4%) and severe TR 2 (2%) in cases.&#x0D; Conclusion: Tricuspid incompetence following endocardial leads implantation is not rare and occurred in approximately 10% of our patients. This complication may be preventable, because it is likely due to the interference of the endocardial lead with the TV.

Proposing novel methods for simultaneous cardiac cycle phase identification and estimating maximal and minimal left atrial volume (LAV) from apical four-chamber view in 2-D echocardiography

1 Abstract Left atrial volume (LAV) estimation is an important issue for prognosis of some adverse cardiovascular events. Manual estimation of LAV is a tedious and time-consuming labor. LAV measurement is a challenging task due to some factors such as artifacts and speckle noise generated by ultrasound imaging, vague boundaries of anatomical structures, viewpoint variations and different scanning angles. Therefore, using automatic methods for estimating LAV is necessary. In this study, our aim is estimating maximal and minimal LAV from echocardiographic images. Moreover, cardiac cycle phase is identified via recognizing end-systole and end-diastole frames as the main prerequisite of LAV measurement. Different from the previous studies, this study proposes novel methods which does not require any image segmentation to perform simultaneously key-frame identification and LAV estimation. For this purpose, four different scenarios are designed, evaluated and compared using a 5-fold cross-validation strategy. Our collected dataset includes the apical four-chamber (A4C) view of 2-D echocardiography videos (621 videos with the resolution of 768 × 1024 pixels) taken from patients in Tehran Heart Center. The key-frames and their corresponding minimal and maximal LAV are determined by experts for this dataset. Experimental results show that the fourth proposed scenario outperforms the compared methods with an average accuracy of 93.68 ± 0.74 for key-frame identification and mean square error of 0.08 ± 0.01 for LAV estimation. The proposed scenario can be used in a fully automated manner for CAD software and mobile applications.

Evaluation of left ventricular systolic functions in two-dimensional speckle-tracking echocardiography in children with chronic renal failure.

Chronic kidney disease may lead to left ventricular dysfunction. Early detection of cardiovascular disease in children with chronic kidney disease is essential to prevent cardiovascular morbidity and mortality in early adulthood. This study aimed to document the dysfunction using methods such as two-dimensional speckle-tracking echocardiography in the early stage. A total of 34 patients diagnosed with chronic kidney disease (mean age ± standard deviation, 10.5 ± 4.1 years) and 37 sex- and age-matched (mean age 9.8 ± 4.2 years) healthy controls were studied. The results of the two groups were compared along with those of the published studies. The echocardiography measurements had no significant difference in the end-diastolic and end-systolic diameter values of left ventricular, ejection fraction, shortening fraction, mitral E value, mitral A value, and E/A ratio between the groups. Pulmonary artery systolic and diastolic pressure and left ventricular mass index were significantly higher in the patient group (p < 0.01). The longitudinal global strain values in the apical four-chamber, three-chamber, and two-chamber views and the total global strain values were significantly lower in the patients (p < 0.01). The circumferential global strain values in the apical, mid, basal, and total global strain were lower in the patient group, but this difference was statistically significant in the apical global and total global strain values (p < 0.05). Speckle-tracking echocardiography might help identify subclinical left ventricular dysfunction in patients with chronic kidney disease with unremarkable conventional echocardiography.

Two-dimensional echocardiographic estimates of left ventricular volumes obtained in different views in dogs provide similar measurements but are not interchangeable

IntroductionLittle information exists regarding the interchangeability of left ventricular volume estimates using a monoplane Simpson's Method of Discs on images obtained from the left apical four-chamber and right parasternal long axis four-chamber views. We examined if volume estimates obtained from these views were interchangeable. AnimalsA total of 224 dogs: 86 healthy, 96 with mitral valve disease, 42 with various cardiac pathologies. Materials and methodsInvestigators obtained right parasternal long-axis and left apical four-chamber views from each dog and used manufacturer-supplied software to estimate left ventricular volumes in diastole and systole using Simpson's Method of Discs. Estimates based on linear measurements (diameter cubed, 0.67∗diameter cubed, and Teichholz) were also calculated. Reproducibility for each view, and agreement between the estimates obtained with each view, and those calculated from linear dimensions, were examined using Limits of Agreement. Reference intervals for volumes indexed to bodyweight and body surface area were calculated. ResultsNeither method proved very reproducible. Although no bias was detected, the agreement between volumes indexed to bodyweight and body surface area was insufficient to recommend interchangeability. Estimates based on Teichholz and diameter cubed methods overestimated volumes; however, those based on 0.67∗diameter cubed performed reasonably. ConclusionsMonoplane volume estimates from the left apical and right parasternal long axis four-chamber views are similar but not interchangeable. Clinicians can perform crude estimates of left ventricular volume using the equation 0.67∗diameter cubed.

Prognostic Value of the Right Ventricular Ejection Fraction, Assessed by Fully Automated Three-Dimensional Echocardiography: A Direct Comparison of Analyses Using Right Ventricular–Focused Views versus Apical Four-Chamber Views

Right ventricular (RV) three-dimensional echocardiographic (3DE) data sets are acquired from either the RV-focused view (RVFV) or the apical four-chamber view (4CV). The prognostic value of 3DE RV ejection fraction (RVEF) was investigated using fully automated RV quantification software, and how measurement values with 3DE data sets from the RVFV compare with those from the 4CV was determined. One hundred seventy-four patients who had undergone both cardiac magnetic resonance (CMR) and 3DE imaging were retrospectively selected. RV 3DE data sets were acquired from both the RVFV and the 4CV and were analyzed separately using fully automated RV quantification software. Primary end points were cardiac events, including cardiac death, heart failure requiring hospitalization, nonfatal myocardial infarction, and ventricular tachyarrhythmia. The feasibility of RVEF measurements on 3DE imaging from the RVFV and 4CV was 92% and 92%, respectively. There was good correlation (r=0.83) and small bias (0.3%) between RVEF from the RVFV and that from the 4CV. Similar results were obtained when only data from patients whose echocardiograms had poor image quality in one or both views were analyzed (r=0.83, bias=1.7%, n=78). Although fully automated analysis in both the RVFV and 4CV significantly underestimated RV volumes compared with CMR, neither measurement differed significantly for RVEF compared with CMR. During a median follow-up period of 12.5months, 21 patients experienced primary end points. RVEF assessed by CMR and 3DE imaging was significantly associated with cardiac events. RVEF using fully automated analysis had a significant association with cardiac events, even in patients with poor image quality (RVFV: hazard ratio, 0.90 [P=.009, n=44]; 4CV: hazard ratio, 0.90 [P=.009, n=68]). RV 3DE data sets from the RVFV and 4CV yielded similar RVEF values using fully automated software. RVEFs from both approaches had significant association with outcomes. Thus, both provide accurate information regarding RV function and risk for adverse outcomes.

Accurate prediction of left ventricular diastolic dysfunction in 2D echocardiography using ensemble of deep convolutional neural networks

Abstract Introduction Deep convolutional neural networks (CNNs) have been shown to be reliable in evaluating geometrically assessed systolic heart function, however, studies evaluating diastolic heart function, which reflects hemodynamic status, are scarce. This study presents a novel CNNs approach for recognition and evaluation of different diastolic left ventricular (LV) function measurements. Purpose To create a new CNNs approach in the assessment of LV diastolic function and compare the results with clinicians' measurements. Methods A total of 4586 2D echocardiographic images were extracted from the studies of 330 patients referred with varying indications. The ensemble of four CNNs was trained (80/20% training/validation patient split) for the assessment of transmitral inflow (E and A wave peak velocities), mitral septal and lateral annular velocities (e'), tricuspid regurgitation systolic velocity (Vmax) and detection the left atrial endocardium in apical four-chamber views. Additionally, E/A ratio, average E/e' ratio and left atrial volume index (LAVi) values were calculated for the evaluation of diastolic dysfunction according to the 2016 ASE/EACVI recommendations. CNNs performance in detecting diastolic dysfunction was compared to expert cardiologists on a set of 20 separate cases. Results Study results on the validation data showed that CNNs accurately predicted peak E/A ratio, average E/e' ratio (R2=0.88 and R2=0.89, respectively) and tricuspid regurgitation Vmax (R2=0.82). Figure 1 illustrates different functional LV measurements among the obtained echocardiographic images. Regarding the geometrical assessment of diastolic function, the segmentation model traced the left atrial endocardial border (intersection over union = 0.94) and subsequently was used in predicting the LAVi (R2=0.92). The ensemble of four CNNs had the area under the ROC curve of 0.93 for the detection of diastolic dysfunction when compared to expert cardiologists. Conclusion Deep CNNs demonstrate the capacity to detect peak velocities across different Doppler imaging modes and delineate left atrial endocardium border while using a relatively small dataset. Combining multiple CNNs has the potential of performing an accurate assessment of the diastolic LV function. Funding Acknowledgement Type of funding source: None

Optimization of Echo Views for Percutaneous Device Closure of Pediatric Atrial Septal Defect through the Femoral Vein Guided by Transthoracic Echocardiography without Radiation.

Objectives This study aimed to explore the selection of views for transthoracic echocardiography-guided transfemoral puncture for the device closure of pediatric atrial septal defect (ASD) without radiation. Methods Sixty children (29 males and 31 females) were diagnosed with a central ASD, normal heart function, and no other intracardiac deformity. All procedures were performed in a surgical operating room (without radiological equipment) under basic anesthesia; the femoral vein pathway and guidance by only transthoracic echocardiography were used to complete the device closure of the ASD. The subcostal acoustic window and parasternal aorta short-axis views were used to guide the extra stiff wire and catheter into the left atrium. All procedures were performed under the subcostal biatrial section. The sheath entered the left atrium, and the apical four-chamber view was used to monitor the delivery and release of the occluder. Results Successful closure of the ASD was achieved in all cases. The operating time from the end of the puncture to the release of the occluder was 10.36 ± 3.57 minutes. No other incisions were needed in 60 cases. No occluders were removed, and no residual shunt or pericardial effusions were detected after the procedures, during the non-ICU stay time. The average hospital stay was 2.19 ± 0.58 days. Conclusion The accurate selection of transthoracic echocardiographic views can better ensure the safety and effectiveness of ASD closure through the femoral vein without radiation in children.

Impaired left ventricular global longitudinal strain is associated with elevated left ventricular filling pressure after myocardial infarction.

Left ventricular (LV) global longitudinal strain (GLS) has emerged as a significant prognostic marker in patients after myocardial infarction (MI). Although elevated LV filling pressure after MI might alter GLS, direct evidence for this is lacking. This study aimed to clarify the association between GLS and LV filling pressure in a large animal MI model. A total of 104 Yorkshire pigs underwent both echocardiographic and hemodynamic assessments 1-4 wk after induction of large anterior MI. GLS was measured in the apical four-chamber view using a semiautomated speckle-tracking software. LV pressure-volume relationship was invasively measured using a high-fidelity pressure-volume catheter. GLS >-14% was considered impaired. Compared with pigs with LV ejection fraction (LVEF) >40% and preserved GLS (n = 29), those with LVEF >40% and impaired GLS (n = 37) and those with LVEF ≤40% (n = 38) had significantly higher LV end-diastolic pressure (15.5 ± 5.5 vs. 19.7 ± 5.8 and 19.6 ± 6.6 mmHg; P = 0.008 and P = 0.026, respectively) and higher LV mean diastolic pressure (7.1 ± 2.9 vs. 10.4 ± 4.5 and 11.1 ± 5.4 mmHg; P = 0.013 and P = 0.002, respectively). GLS was modestly correlated with τ (r = 0.21, P = 0.039) and slope of LV end-diastolic pressure-volume relationship (r = 0.43, P < 0.001). Impaired GLS was associated with higher LV end-diastolic and mean-diastolic pressures after adjusting for LVEF and baseline characteristics (P = 0.026 and P = 0.001, respectively). Impaired GLS assessed by speckle-tracking echocardiography was associated with elevated LV filling pressure after MI. GLS has an incremental diagnostic value for detecting elevated LV filling pressure and may be particularly useful for evaluating post-MI patients with preserved LVEF.NEW & NOTEWORTHY Strain analysis was performed in 104 pigs after MI, and its relationship to invasive hemodynamic measurements was studied. Impaired longitudinal strain was associated with high ventricular filling pressure independent of LVEF in post-MI setting. Global longitudinal strain is a potential prognostic marker after MI.

Evaluation of left ventricular myocardial movement in rats by velocity vector imaging.

AimTo use velocity vector imaging (VVI) technology to evaluate the correlation between the apical four-chamber view and short-axis myocardial movement in rats.MethodsWe used 25 10-week-old male Sprague-Dawley rats to measure the myocardium peak systolic velocity (Vs; cm/s), peak diastolic velocity (Vd; cm/s), peak systolic strain (SR; %), peak systolic strain rate (SRs; 1/s), and peak diastolic strain rate (SRd; 1/s) from the apical four-chamber view of the left ventricle (LV) and the parasternal mitral valve (PMV)-level short-axis view, and to analyze the correlation between myocardial motion in corresponding views of the two sections.ResultsComparing the myocardial motion between the lateral wall’s basal segment in the apical four-chamber view of the LV and the lateral wall of the PMV-level short-axis view revealed that the Vd was positively correlated (r = 0.59, p<0.01), as was SRs (r = 0.68, p<0.05). Comparing the myocardial motion between the lateral wall’s middle segment in the apical four-chamber view of the LV and the lateral wall of the PMV-level short-axis view demonstrated that Vd, SRs, and SRd were positively correlated (r = 0.63, 0.82, 0.79, respectively, all p<0.01). Our comparison of myocardial motion between the posterior septum’s basal segment in the apical four-chamber view of the LV and the posterior septum of PMV-level short-axis view showed that Vd and SRs were positively correlated (r = 0.57, 0.68, respectively, both p<0.01). Comparing the myocardial motion between the posterior septum’s middle segment in the apical four-chamber view of the LV and the posterior septum of the PMV-level short-axis view revealed that Vs, Vd, SR, and SRd were positively correlated (r = 0.89, 0.63, 0.64, 0.6, respectively, all p<0.01), and the SRs also had a significant positive correlation (r = 0.53, p<0.05).ConclusionVVI technology could be a valuable tool for evaluating the myocardial walls motion of the apical four-chamber view of the rat LV.

The feasibility of measurement of different right ventricular systolic function parameters by intraoperative trans-esophageal echocardiography and their interchangeability with transthoracic echocardiography in pediatric patients undergoing cardiac surgery- interim results from an ongoing study

Introduction All the parameters recommended for functional assessment of right ventricle (RV) in children are based on transthoracic echocardiographic (TTE) measurements¹. Intraoperative echocardiography during pediatric cardiac surgery is, however, mainly dependent on trans-esophageal echocardiography (TEE). We planned to determine the feasibility of measurement of different RV systolic function parameters by intraoperative TEE and their interchangeability with TTE in pediatric patients undergoing cardiac surgery. Methods This ongoing single-centre, observational study has been registered (CTRI/2019/06/019743) after Institutional Ethics Committee clearance. After written, informed, parental consent, pediatric patients (1-18 years) undergoing corrective surgery for congenital heart diseases- are included. TEE transducer is inserted after induction of general anaesthesia. TTE examination is performed using Apical four-chamber (A4C) view. TEE examination is performed within 10 minutes of performing TTE, while keeping heart rate, mean arterial pressure and central venous pressure within 10% of that during performing TTE. Mid-esophageal four-chamber RV-focused (ME4C) view, Mid-esophageal modified bicaval view (MBC), Transgastric RV inflow view (TGRVI), Deep transgastric RV view (DTG-RV)- are used. All the recorded images/clips are analysed offline later, using Echopac-113 (GE) software. Fractional Area Change (FAC), Tricuspid annular plane systolic excursion (TAPSE), Tricuspid annular systolic velocity by pulsed-wave tissue Doppler (RV S’), Right ventricular index of myocardial performance (RIMP) (by tissue Doppler), Right ventricular free wall strain (RVFWS)- are measured. Feasibility is assessed as ability to acquire an image/loop deemed readable during the examination. Readable image/loop is defined as ability to completely delineate the endocardial border of the RV and tricuspid annulus in 2D-mode, to obtain completely traceable lines in M-mode (MM) and Angled M- mode (AMM), to obtain optimally aligned and completely traceable envelopes of pulsed wave Tissue-Doppler velocities. Agreement between TTE and TEE measured parameters are assessed by Bland-and-Altmann analysis. Results 42 patients has been recruited and analysed so far. The Mean±SD age of the patients was 6.5±4.6 years. Feasibility of measuring all the studied parameters was > 85% in all the TEE views (Table 1). There was good Intra- and Inter-observer reliability (Intra-class Correlation Coefficient > 0.8) of measurements of all the parameters in all the views (Both TTE and TEE) utilised. In comparison to TTE measurements, there were low bias in TEE measured parameters in: AMM measured TAPSE in ME4C and MBC views, FAC in ME4C view, RIMP in DTG-RV and TGRVI views, RVFWS in all the utilised views (Table 1). The limits of agreements, however, were wide (Table 1). Discussion Despite high feasibility, wide limits of agreement prevents intraoperative TEE measured RV function parameters to be used interchangeably with those measured by TTE for individual pediatric cardiac surgical patients.

Early changes in myocyte contractility and cardiac function in streptozotocin-induced type 1 diabetes in rats

Diabetes can elicit direct deleterious effects on the myocardium, independent of coronary artery disease or hypertension. These cardiac disturbances are termed diabetic cardiomyopathy showing increased risk of heart failure with or without reduced ejection fraction. Presently, there is no specific treatment for this type of cardiomyopathy and in the case of type I diabetes, it may start in early childhood independent of glycemic control. We hypothesized that alterations in isolated myocyte contractility and cardiac function are present in the early stages of experimental diabetes in rats before overt changes in myocardium structure occur. Diabetes was induced by single-dose injection of streptozotocin (STZ) in rats with data collected from control and diabetic animals 3 weeks after injection. Left ventricle myocyte contractility was measured by single-cell length variation under electrical stimulation. Cardiac function and morphology were studied by high-resolution echocardiography with pulsed-wave tissue Doppler imaging (TDI) measurements and three-lead surface electrocardiogram. Triglycerides, cholesterol and liver enzyme levels were measured from plasma samples obtained from both groups. Myocardial collagen content and perivascular fibrosis of atria and ventricle were studied by histological analysis after picrosirius red staining. Diabetes resulted in altered contractility of isolated cardiac myocytes with increased contraction and relaxation time intervals. Echocardiography showed left atrium dilation, increased end-diastolic LV and posterior wall thickness, with reduced longitudinal systolic peak velocity (S’) of the septum mitral annulus at the apical four-chamber view obtained by TDI. Triglycerides, aspartate aminotransferase and alkaline phosphatase were elevated in diabetic animals. Intertitial collagen content was higher in atria of both groups and did not differ among control and diabetic animals. Perivascular intramyocardial arterioles collagen did not differ between groups. These results suggest that alterations in cardiac function are present in the early phase in this model of diabetes type 1 and occur before overt changes in myocardium structure appear as evaluated by intersticial collagen deposition and perivascular fibrosis of intramyocardial arterioles.

Mitral Annular Plane Systolic Excursion: An Early Marker of Mortality in Severe COVID-19

Mitral Annular Plane Systolic Excursion: An Early Marker of Mortality in Severe COVID-19

The value of 2D speckle-tracking strain echocardiography in evaluating the relationship between carotid elasticity and left ventricular systolic function in patients with diabetic nephropathy

ObjectiveTo investigate the relationship between the elasticity of the carotid artery and the LV (left ventricle) systolic function in patients with diabetic nephropathy (DN) by using two-dimensional speckle-tracking strain echocardiography (2D-STE).MethodsDN patients (n = 108) and control subjects (n = 112), all of whom underwent echocardiography and carotid ultrasound. Analysis of LV GLS (global longitudinal strain) from the apical two-chamber (2C), three-chamber (3C), and four-chamber (4C) views. Meanwhile, the circumferential strain (CS) of the carotid artery was obtained from the view of the short-axis right common carotid artery. The differences between the two groups were compared, and a correlation analysis between CS and GLS was performed.ResultsThe 4CGLS, 2CGLS, 3CGLS, and CS of the DN group were significantly lower at significant levels in contrast to the control group (p < 0.05). There was a significantly positive correlation of CS with 4CGLS, 2CGLS, and 3CGLS in all subjects (r = 0.809, p = 0.000; r = 0.830, p = 0.000; r = 0.830, p = 0.000, respectively).Conclusion2D-STE is a relatively new technique for assessing the mechanical characteristics of the carotid artery in patients with DN. Reduced values of CS correlate with reduced LV systolic function as evaluated by strain measurements, which can predict the risk of systolic dysfunction of LV.

Assessment of Longitudinal Left Ventricle Deformation by 2-Dimensional Speckle Tracking Echocardiography Obtained from Different Views in Cats

Two-dimensional speckle tracking echocardiography (STE) is a novel, angle-independent imaging technique useful to assess myocardial function by strain and strain rate analysis in human and veterinary medicine. Commonly, the left apical four-chamber (LAP4Ch) view is used to assess left ventricular (LV) longitudinal deformation in dogs and cats. However, the right parasternal four-chamber (RP4Ch) view is often more easily obtained than the LAP4Ch view in cats. No studies exist comparing longitudinal strain and strain rate values using STE from different echocardiographic views in cats. Therefore, we examined the agreement between RP4Ch and LAP4Ch for assessment of LV longitudinal strain and strain rate in cats. We acquired 2D echocardiographic cineloops from RP4Ch and LAP4Ch views and analyzed LV longitudinal strain and strain rate in 50 cats (31 healthy cats and 19 cats with different disease states) using XstrainTM software. Peak systolic strain and strain rate values of endocardial and epicardial border were used for the analysis. The two echocardiographic views were compared using limits-of-agreement analyses and intra-observer measurement variability was assessed. We could obtain longitudinal strain and strain rate from the RP4Ch view in all cats. Strain, but not strain rate, had good intra-observer measurement variability (<10% vs. <20%). However, only endocardial strain values obtained with the two views agreed sufficiently to be used interchangeably (95% limits of agreement: −3.28, 2.58). Epicardial strain/strain rate and endocardial strain rate values did not agree sufficiently to be used interchangeably (95% limits of agreement: −11.58, 9.19; −2.28, 1.74; −1.41, 1.36, respectively). Our study suggests that RP4Ch view was feasible for assessment of the LV longitudinal deformation analysis by STE in cats, but only endocardial longitudinal strain values obtained from the two different views were interchangeable.

Deep RetinaNet for Dynamic Left Ventricle Detection in Multiview Echocardiography Classification

Background. Currently, echocardiography has become an essential technology for the diagnosis of cardiovascular diseases. Accurate classification of apical two-chamber (A2C), apical three-chamber (A3C), and apical four-chamber (A4C) views and the precise detection of the left ventricle can significantly reduce the workload of clinicians and improve the reproducibility of left ventricle segmentation. In addition, left ventricle detection is significant for the three-dimensional reconstruction of the heart chambers. Method. RetinaNet is a one-stage object detection algorithm that can achieve high accuracy and efficiency at the same time. RetinaNet is mainly composed of the residual network (ResNet), the feature pyramid network (FPN), and two fully convolutional networks (FCNs); one FCN is for the classification task, and the other is for the border regression task. Results. In this paper, we use the classification subnetwork to classify A2C, A3C, and A4C images and use the regression subnetworks to detect the left ventricle simultaneously. We display not only the position of the left ventricle on the test image but also the view category on the image, which will facilitate the diagnosis. We used the mean intersection-over-union (mIOU) as an index to measure the performance of left ventricle detection and the accuracy as an index to measure the effect of the classification of the three different views. Our study shows that both classification and detection effects are noteworthy. The classification accuracy rates of A2C, A3C, and A4C are 1.000, 0.935, and 0.989, respectively. The mIOU values of A2C, A3C, and A4C are 0.858, 0.794, and 0.838, respectively.

Mitral leaflet separation index for mitral valve assessment during balloon mitral valvuloplasty.

The objective of the study was to evaluate the accuracy of the mitral leaflet separation index (MLSI) in selected patients with mitral stenosis, before and after percutaneous balloon mitral valvuloplasty (PBMV), compared to conventional methods with transthoracic echocardiography [TTE]. A prospective study was conducted in 30 patients, ages 20-60years, with severe symptomatic mitral stenosis (MS) who had PBMV in the Cardiology Department, Zagazig University and National Heart Institute. A mean of three to five measurements of MLSI was taken in diastole in the parasternal long-axis and apical four-chamber views. The MLSI was re-measured 24-48hours after PBMV. We calculated the correlation of the MLSI, pre and post BMV, with two-dimensional (2D) MV planimetry and pressure half-time (PHT) methods to assess MVA. There was a positive, highly significant correlation between pre PBMV 2D planimetry and MLSI (r=.665, P-value<.001) as well as post PBMV 2D planimetry and MLSI (r=.410, P-value=.025). A positive highly significant correlation was also noted between pre PBMV PHT and MLSI (r=.678, P-value <.001) and between post PBMV PHT and MLSI (r=.706, P-value <.001). Mitral leaflet separation index is an easy and reliable measurement for the assessment of mitral stenosis before and after PBMV.

Speckle Tracking Echocardiography in Pediatric Patients with Premature Ventricular Contractions.

Premature ventricular contractions (PVCs) in pediatric patients without structural heart disease and normal left ventricular systolic function rarely require therapy, though it is unknown whether these patients have subclinical cardiac dysfunction. Speckle tracking echocardiography is an additional means of evaluating cardiac function in asymptomatic pediatric PVC patients with normal standard measures of left ventricular (LV) function. Asymptomatic pediatric patients (< 21years) without congenital heart disease, LV ejection fraction (LVEF) ≥ 55% and PVC burden ≥ 5% on 24-h Holter monitor were included. Demographic information, exercise stress test results, standard echocardiographic measures of LV systolic function and PVC morphology by 12-lead ECG were collected. Peak global systolic longitudinal strain (GLS) from apical four-chamber view was analyzed offline. 29 patients were identified (mean age 11.7 ± 5.8years, 49.2 ± 25.3kg, 59% male). Mean PVC burden was 12.0 ± 7.0% (range 5-37.5%). 14/29 (48%) had exercise stress testing with evidence of PVCs; 9/14 (64%) had PVC suppression at a mean heart rate (HR) of 160 ± 23bpm and 5/14 (36%) did not suppress at a mean maximum HR of 188 ± 9bpm. All patients had normal strain values by speckle tracking echocardiography (mean LV GLS - 22.5 ± 2.0%, LV global circumferential strain - 25.3 ± 3.9 and RV GLS - 24.1 ± 3.0%). There was no correlation between PVC burden and cardiac function parameters. Asymptomatic pediatric patients without structural heart disease, preserved LVEF/shortening fraction and PVC burden ≥ 5% demonstrated normal cardiac function including strain patterns indicating no evidence of subclinical cardiac dysfunction. Larger scale studies and longitudinal evaluation of left ventricular function using speckle tracking echocardiography is warranted in this population.