Apical View Research Articles

Echocardiography, apical 4-chamber view showing sustained normal LV function (ejection fraction 55%) at 4-year follow up.

Echocardiography, apical 4-chamber view showing sustained normal LV function (ejection fraction 55%) at 4-year follow up.

Echocardiography, apical 4-chamber view at 6-month follow-up showing normal systolic function (ejection fraction 60%).

Echocardiography, apical 4-chamber view at 6-month follow-up showing normal systolic function (ejection fraction 60%).

Echocardiography, apical 4-chamber view at presentation showing a dilated left ventricle with severely reduced systolic function and ejection fraction of 15%.

Echocardiography, apical 4-chamber view at presentation showing a dilated left ventricle with severely reduced systolic function and ejection fraction of 15%.

1762. Clinical application of handheld ultrasound devices during the 2022 Sudan Virus disease Ebola outbreak in Uganda

Abstract Background The fluid status and causes of respiratory failure in patients with Ebola disease can be challenging to determine due to concomitant severe diarrhea, vascular leakage, and multiorgan failure. Point-of-care ultrasound (POCUS) could guide fluid resuscitation for patients in resource-limited settings. We present the clinical application of POCUS in the 2022 Sudan Virus disease Ebola outbreak in Uganda. Figure. Ultrasound findings from patient 2. 2A: Discrete B lines observed with an irregular pleural line; 2B: Inferior vena cava collapsibility <50% suggestive of adequate fluid resuscitation; 2C: parasternal short cardiac view with small pericardial effusion identified; 2D: apical cardiac view with small pericardial effusion redemonstrated. Methods A clinical research team in Fort Portal, Uganda was trained in advanced Infection Prevention and Control (IPC) to care for patients with Ebola disease and in POCUS for septic shock. The clinical team learned a standardized lung and cardiac critical care ultrasound approach to evaluate patients in septic shock. The scanning procedure was used during the care of 6 patients with confirmed Sudan virus disease within 2 weeks of outbreak declaration to make critical patient care decisions like fluid management. Chest X-ray services and mechanical ventilation were not accessible. A handheld Philips Lumify device was kept in the biocontainment area and was used in full personal protective equipment. Scanning procedures included 12-zone lung ultrasound and 4-view cardiac ultrasound scans to determine causes of respiratory disease and evaluate fluid status. Results Among 6 patients (age range 27 to 58 years; 1/6 female), 5/6 were in their third week of illness, and 1/6 was in his second week of illness. Lung ultrasound abnormalities included discrete B-lines (5/6 patients), confluent B-lines (1/6), irregular pleural lines (3/6 patients), and subpleural consolidations (1/6 patients). Two participants in respiratory distress had cardiac POCUS. Both had hyperdynamic left ventricular function and one had a small pericardial effusion (Figure). One patient had inferior vena cava (IVC) collapsibility < 50% (1.5 cm diameter), and another with a >50% IVC collapsibility (1.3 cm diameter). These findings contributed to a decision to continue fluid resuscitation. Conclusion Portable handheld ultrasound devices identified previously undescribed ultrasound features of Sudan virus disease. POCUS helped determine causes of respiratory failure and guided fluid resuscitation in a biocontainment ward without access to mechanical ventilation. Disclosures All Authors: No reported disclosures

Speckle tracking echocardiography for diagnosis of right ventricular failure in children with totally corrected tetralogy of Fallot in Sulaimani, Iraq

ObjectivesThe study was aimed at using speckle tracking echocardiography as a novel technique to diagnose right ventricular failure (RVF) in children with total correction of tetralogy of Fallot (TOF) through surgery. MethodsA quasi-experimental study was performed at the Children's Heart Hospital of Sulaimani for 9 months. A total of 150 children with completely repaired TOF were enrolled to investigate RVF. Conventional echocardiographic data were recorded, including right ventricular (RV) ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), and RV end-systolic and diastolic volume (RVESV and RVEDV). Additionally, speckle tracking was performed for the regional and longitudinal strain and strain rate in four-chamber apical view. RVF diagnosis was determined on the basis of electrocardiography measurement of P-wave dispersion, T-wave dispersion, and QRS duration. ResultsChildren with repaired TOF who were diagnosed with RVF through conventional echocardiography exhibited abnormalities with respect to children with normal RV function, including a TAPSE of 1.3 ± 0.11 cm, RVEF of 35.5 ± 6.72, RVESV of 69.8 ± 15.13 ml, RVEDV of 110.1 ± 14.13 ml, MPI of 0.60 ± 0.12, and Pmax of 52.4 ± 14.08. The use of speckle tracking in RVF diagnosis revealed a relatively lower longitudinal strain and strain rate (−12.1 ± 2.3 and −0.9 ± 0.3, respectively) in the children with RVF. Moreover, longitudinal right ventricular strain was positively correlated with TAPSE (r = 0.656) and EF (r = 0.675), and negatively correlated with RVEDV (r = −0.684), RVESV (r = −0.718), MPI (r = −0.735), and Pmax (r = −0.767). ConclusionsThe application of speckle tracking with the longitudinal RV strain and strain rate to estimate RV function in children with repaired TOF is a new advanced method that, compared with conventional echo, significantly improves the diagnosis of regional myocardial deformations and cardiac muscle motion velocity.

Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units.

Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.

Automatic Segmentation and Assessment of Valvular Regurgitations with Color Doppler Echocardiography Images: A VABC-UNet-Based Framework.

This study investigated the automatic segmentation and classification of mitral regurgitation (MR) and tricuspid regurgitation (TR) using a deep learning-based method, aiming to improve the efficiency and accuracy of diagnosis of valvular regurgitations. A VABC-UNet model was proposed consisting of VGG16 encoder, U-Net decoder, batch normalization, attention block and deepened convolution layer based on the U-Net backbone. Then, a VABC-UNet-based assessment framework was established for automatic segmentation, classification, and evaluation of valvular regurgitations. A total of 315 color Doppler echocardiography images of MR and/or TR in an apical four-chamber view were collected, including 35 images in the test dataset and 280 images in the training dataset. In comparison with the classic U-Net and VGG16-UNet models, the segmentation performance of the VABC-UNet model was evaluated via four metrics: Dice, Jaccard, Precision, and Recall. According to the features of regurgitation jet and atrium, the regurgitation could automatically be classified into MR or TR, and evaluated to mild, moderate, moderate-severe, or severe grade by the framework. The results show that the VABC-UNet model has a superior performance in the segmentation of valvular regurgitation jets and atria to the other two models and consequently a higher accuracy of classification and evaluation. There were fewer pseudo- and over-segmentations by the VABC-UNet model and the values of the metrics significantly improved (p < 0.05). The proposed VABC-UNet-based framework achieves automatic segmentation, classification, and evaluation of MR and TR, having potential to assist radiologists in clinical decision making of the regurgitations in valvular heart diseases.

Left atrial strain as an independent predictor of sinus rhythm maintenance after catheter ablation for paroxysmal atrial fibrillation in HFpEF patients

Abstract Background The early AF treatment by radio-frequency catheter ablation (CA) is very important for improving clinical outcome in patients with history of atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Left atrial (LA) strain showed to be a useful index to monitor atrial function in AF and HFpEF states. However, the accuracy of LA strain to predict the long-term maintenance of sinus rhythm (SR) in HFpEF patients with paroxysmal AF undergoing CA is still under debate. Aims To define the best echocardiography derived parameters to predict the long-term maintenance of SR in paroxysmal AF patients with high probability of HFpEF undergoing CA. Methods We prospectively enrolled 200 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%). All patients had a H2FPEF score suggesting high probability of HFpEF. During sinus rhythm, all patients underwent comprehensive transthoracic echocardiography at baseline, including assessment of left ventricular (LV) global longitudinal strain (GLS), left atrial (LA) reservoir strain (LASr), LA conduit strain (LAScd) and LA contractile strain (LASct) using two-dimensional speckle tracking in apical views. Results After 42+/-8 months follow-up, a total of 34 (17%) patients had a documented recurrence of AF. Patients with AF recurrence had lower LASr (22.2% vs. 28.3%, p &amp;lt; 0.001) and LASct (10.9% vs. 13.2%, p &amp;lt; 0.01) compared to patients who keep on SR. Among speckle tracking derived LA phasic strain indices, LASr showed the largest area under the curve (AUC = 0.8, p &amp;lt; 0.001) and the strongest independent predictive value (LASr &amp;gt; 22%) of long-term maintenance of SR with sensitivity of 80% and specificity of 66% (Figure 1). Other parameters of LA function, LA diameter, maximum or minimum LA volume index, LV GLS or ejection fraction, and indices of LV diastolic function had lower area under the curve. Using multivariable logistic regression, only LASr (OR 0.89, 95% CI 0.81-0.97, p=0.013) was independently associated with long-term SR maintenance while other LA size and function indices were not. Conclusion In HFpEF patients with paroxysmal AF undergoing CA, LASr is more accurate predictor of SR maintenance than other standard echocardiographic parameters in long-term follow-up.

Left atrial strain and long-term risk of atrial fibrillation in hypertrophic cardiomyopathy

Abstract Background The prevalence of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is higher than in the general population, and it is associated with an increased risk of adverse outcomes, such as stroke, heart failure, and mortality. The left atrium (LA) plays an important role in maintaining normal cardiac function, and alterations in its structure and function can contribute to the development of AF. LA strain, a surrogate of LA remodeling, has been suggested a predictor of future AF. Purpose The aim of this study was to explore risk factors of new onset AF highlighting LA strain in patients with HCM. Methods Among a prospective cohort of 865 HCM patients collected at two large tertiary centers, 696 with adequate echocardiographic images to measure LA strain without a history of AF were included in the analysis. LA strain was measured on apical four-chamber view at initial evaluation using vendor-independent speckle-tracking software. The primary endpoint was new onset AF during 10 years after initial evaluation. Results The median age was 55.0 years and 74.3% were male. A median value of LA reservoir strain (LARS) was 26.2 % [interquartile range 20.4, 33.3]. Among the 696 patients, 66 had new onset AF 10 years, with a 10-year incidence of 15.8%. The unadjusted risk factors for new onset AF were previous stroke, non-apical HCM, family history of HCM, non-sustained ventricular tachycardia, obstructive HCM, extensive late gadolinium enhancement, larger LA diameter, larger LA volume, and lower LARS. LARS remained an independent predictor of new onset AF in multivariable analysis. The best cut-off value of LARS was 17.9% (hazard ratio 4.00, 95% confidence interval 2.44–6.55, p&amp;lt;0.001). Compared with LARS ≥17.9%, LARS &amp;lt;17.9% was significantly associated with a higher incidence of new onset AF, irrespective of presence of clinical risk factors (Figure 1) and LA enlargement (Figure 2). Conclusions In patients with HCM, low LA strain is an independent predictor of new onset AF.

The prevalence of congenital cardiac tumours in unselected newborns

Abstract Background Primary cardiac tumours in children are rare. The most common cardiac tumour in newborns is rhabdomyomas, associated with tuberous sclerosis in &amp;gt;50% of cases. The estimated prevalence is 0.14‰ in fetuses, whereas in the paediatric population, a 20-fold difference in autopsy prevalence has been reported (0.017‰ to 0.27‰). Purpose To determine the pre- and postnatal prevalence of congenital cardiac tumours in a large, population-based cohort of prenatally enrolled newborns. Methods Systematic transthoracic echocardiography (TTE), including sub-xiphoid, apical, parasternal, and suprasternal views, was performed in unselected newborns included in a population study. Participants were included at time of the routine malformation scan (weeks 18-21), which included 4-chamber view, aortic and pulmonary outflow tracts, and three-vessel view. Cardiac tumours were defined as solid, echogenic masses, and the echocardiographic description included location, size, and number (one/multiple) of the tumour. Information on subsequent diagnosis of tuberous sclerosis was collected from review of medical charts. Results A total of 25,588 newborns (age 12±8 days, 51.6% male) were enrolled and underwent TTE. Prenatally, no cardiac tumours were reported in any of the participants. Postnatally, cardiac tumours were detected in 7 newborns (4 males), corresponding to a prevalence of 0.3 [0.1; 0.6] per 1,000 live-births. Through retrospective review of the prenatal scans, a possible tumour in the ventricle was suspected in 1 of the 7 cases; the remaining 6 cases showed no signs of tumours prenatally. Sex, gestational age at birth, birth length and weight, APGAR 5-score, age and weight at TTE, and maternal age and pre-pregnancy BMI, did not significantly differ between newborns with (n=7) and without (n=25,581) cardiac tumours (all p&amp;gt;0.05). Smoking during pregnancy was significantly more frequent among mothers to newborns with cardiac tumours compared to the remaining cohort (29% vs 4%, p=0.023). In all 7 newborns, the cardiac tumours were located in the ventricles (5 (71%) newborns with tumours in both ventricles, 2 (29%) with tumours in the right ventricle), with multiple tumours seen in 6 (86%), and with size ranging from 2.0x1.9 mm to 10.0x5.1 mm. All 7 newborns had otherwise structurally normal hearts and no flow obstruction. Three newborns with cardiac tumours in the ventricles (43%) were diagnosed with tuberous sclerosis within 4 months after birth. Conclusions Systematic TTE in unselected newborns revealed a prevalence of congenital cardiac tumours of 0.3‰. Prenatal screening in week 18-21 did not seem efficient for identification of cardiac tumours. Cardiac tumours were located in the ventricles and were most often multiple. Cardiac tumours in the ventricles were associated with tuberous sclerosis in almost half the cases. For newborns with cardiac tumours, maternal smoking during pregnancy was common (29%).Figure 1

E-wave propagation index as a marker for left ventricular thrombi post-ST elevation myocardial infarction

Abstract Background The E-wave propagation index (EPI) is a novel echocardiographic measure for quantifying apical washout in the left ventricle (LV) and thus a promising marker of an elevated risk for LV thrombus. The association between EPI and LV thrombus has not been investigated in patients after ST-segment elevation myocardial infarction (STEMI). Purpose Aim was to determine, whether there is an association between EPI and LV thrombus development in STEMI patients treated with primary percutaneous coronary intervention (pPCI). Methods 665 STEMI patients treated with pPCI included in the prospective MARINA-STEMI cohort study (NCT04113356) were investigated. LV thrombus presence was diagnosed via contrast enhanced CMR a median of 4 (interquartile range [IQR] 3–5) days post-STEMI. EPI and left ventricular ejection fraction (LVEF) were measured using transthoracic echocardiography (TTE) a median of 2 ([IQR] 2–3) days post-STEMI. The longitudinal length of the LV was measured in the apical 4-chamber view at end-diastole. Velocity time integral (VTI) of the E-wave was measured using pulsed wave doppler. Results 5% (n=32) of the study population had a LV thrombus. Patients with LV thrombus had lower EPI values compared to patients without LV thrombus (0.92 vs 1.29, p&amp;lt;0.001). EPI (OR 0.21, 95% CI: 0.06-0.73, p&amp;lt;0.014), anterior infarct location (OR 17.18, 95 % CI: 2.25-131.05, p&amp;lt;0.006) and LVEF (OR 0.91, 95 % CI 0.86-0.95, p&amp;lt;0.001) were independently associated with LV thrombus. The optimal cut-off value for the prediction of LV thrombus prediction was an EPI &amp;lt;1 (sensitivity 56.3% and specificity 80.4%). 13% (n=18) of patients with an EPI &amp;lt;1 developed a LV thrombus compared to 3% (n=14) with an EPI≥1. Conclusion In STEMI patients treated with pPCI, a decreased EPI is a novel independent predictor for CMR verified LV thrombus. The optimal cut off for LV thrombus prediction is EPI &amp;lt;1.Center Image EPI

Left atrial strain measurement to predict new-onset atrial fibrillation in ST-elevation myocardial infarction patients

Abstract Background/Introduction ST-elevation myocardial infarction (STEMI) remains a healthcare burden not only through increased mortality risk, but also development of chronic cardiac pathologies like atrial fibrillation (AF). Left atrial (LA) reservoir strain is a known predictor of incident AF in the general population. Purpose Our aim was to explore the additional prognostic value of LA reservoir strain measured by transthoracic echocardiography (TTE) in STEMI patients for new-onset atrial fibrillation (NOAF). Methods Data were analyzed retrospectively from an ongoing STEMI registry. Patients with previous myocardial infarction, AF, known history of heart failure, severe valvular pathology, suboptimal image quality, AF during TTE or missing follow-up were excluded. TTE was performed within 48 hours of hospitalization. LA reservoir strain was measured in apical 4-chamber view. LA strain &amp;lt;23% was used as cut-off value for impaired LA function as previously established. The endpoint was NOAF. Follow-up was censored at last patient visit or at 5 years. Results In total 1238 patients (mean age 60±12 years; 930 (75%) men) were included. After median follow-up of 22 months (IQR 12; 60) 106 (8.6%) patients developed NOAF, most events (71 (67%)) taking place within the first year after STEMI. Mean LA reservoir strain was more impaired in patients who developed NOAF as compared to those who did not (19.3 ± 8.1% versus 24.3 ± 8.8% respectively (p&amp;lt;0.001). Clinical and echocardiographical characteristics are shown in the table. Cumulative event-free survival rates at 1, 3 and 5 years in patients with preserved versus decreased LA strain were 97%, 95% and 93% versus 91%, 89% and 83% respectively (Log-rank X2 = 21.1; p&amp;lt;0.001; Figure). Factors significant on univariable Cox regression analysis (age, presence of chronic obstructive pulmonary disease, troponin levels, left ventricular end-diastolic diameter, interventricular septum diameter, left ventricular global longitudinal strain, LA volume index, LA reservoir strain, E/E’ ratio and right ventricular fractional area change) were included in multivariable model, where LA reservoir strain remained significantly associated with NOAF (HR 0.96 (0.93 – 0.99); p=0.015). Addition of LA strain provided incremental prognostic value over baseline clinical risk factors, traditional TTE parameters and left ventricular global longitudinal strain (X2 84.5 vs 88.8; p=0.013). Conclusion LA reservoir strain was associated with new-onset atrial fibrillation in STEMI patients after adjusting for relevant clinical and echocardiographic risk factors.TableFigure

Standardized longitudinal strain curves stratified by age and sex in healthy individuals: The Copenhagen City Heart Study

Abstract Introduction Speckle-tracking echocardiography has gained widespread use, and strain parameters such as global longitudinal strain (GLS) and strain rates are strongly associated with risk of heart failure and cardiovascular death. Such strain measures, however, only represent limited features of the complete longitudinal strain (LS) curve. Thus, interpretation of entire curves might provide additional insight. Purpose To establish normal standardized LS curves over an entire heart cycle for healthy subjects stratified by age and sex. Furthermore, to assess how these curves vary with age and to compare this with conventional strain measures. Methods The study population consisted of 1790 healthy subjects free of cardiovascular disease and risk factors including diabetes mellitus and hypertension at baseline. Subjects were stratified by sex and further by age in groups as defined in the SCORE risk chart. Subjects underwent echocardiography, and LS curves from the apical four-chamber view were derived and standardized in length using linear interpolation. Terms to describe qualitative findings in the standardized strain curves were established (Figure 1). Early diastolic strain (EDS) was defined as the difference in strain from peak LS to maximal curvature after early diastolic filling, while late diastolic strain (LDS) was defined as the difference in strain from the plateau phase in late passive diastole to maximal curvature in active diastole. Conventional strain measures included GLS, systolic strain rate (SRS), early diastolic strain rate (SRE), and late diastolic strain rates (SRA). The association between these and age group were investigated using univariable linear regression for each sex. Results In the study population, 1101 (61.5%) subjects were female. The standardized strain curves (Figure 2) showed that aging primarily manifested in the diastolic part of the strain curve. Decreasing EDS was associated with increasing age group, while the opposite was true for LDS. In linear regression, both SRE (female: beta=-0.13; p&amp;lt;0.001, male: beta=-0.1; p&amp;lt;0.001) and SRA (female: beta=0.09; p&amp;lt;0.001, male: beta=0.09; p&amp;lt;0.001) were associated with age group for both sexes. Peak LS did not change notably with age, and in linear regression, GLS and SRS were only significantly associated with age for women (GLS: beta=0.12; p&amp;lt;0.001, SRS: beta=0.01; p&amp;lt;0.001). Conclusion We derived normal standardized LS curves for healthy individuals stratified by age and sex, which can serve as normal values in future studies. In addition, these showed that age was primarily associated with changes in the diastolic part of the strain curve in both sexes, which was consistent with conventional strain measures.Figure 1:Overview of termsFigure 2Standardized longitudinal strai

High frame rate speckle tracking echocardiography to visualize the mechanical activation sequence of the left ventricle

Abstract Background Cardiac arrhythmias are a known cause of morbidity and mortality, with catheter ablation being an effective treatment. In order to detect the focal source or the re-entrant circuit of the arrhythmia, i.e. the ablation target, current practice includes performing an electrophysiological study. This technique is invasive, with increased patient related risk and variable success rate. Conversely, echocardiography could be used to determine the correct ablation target. High frame rate (HFR) ultrasound has a temporal resolution adequately high to detect the onset of myocardial deformation and could assist the accurate localisation of the arrhythmia source. Purpose To test whether HFR speckle tracking echocardiography (STE) can be used to create cardiac mechanical activation maps. Methods 18 healthy volunteers (HV) (age 30±6y; 69 %males) and 12 heart failure patients treated with cardiac resynchronisation therapy (CRT) (age 69±10y; 75 %males) were included. All participants were scanned with a research HFR ultrasound scanner (∼849fps) and the 3 standard apical views were acquired. Patients were scanned with CRT on and after turning CRT off, in order to allow intrinsic ventricular conduction. Data from one CRT patient were acquired by temporarily altering the pacing pole of the CRT LV lead. All patients had a left bundle branch block (LBBB) pattern of native activation on the surface ECG. For each view, a manually placed contour was tracked during the cardiac cycle by a custom-made 2D HFR STE algorithm; the contours were divided in a standard 16 segment model and segmental strain rate (SR) curves were computed and used to measure the temporal distance between electrical and mechanical activation (i.e. distance between the beginning of QRS and the first positive to negative zero crossing in the SR curve). Finally, an activation map for each subject was created by placing the extracted timings in the middle of the corresponding segment of a bull’s-eye plot and interpolating values between them. Results Tracking was feasible in 94% of the segments; SR curves showed a physiological pattern (Fig. 1A). For the HV, mechanical activation started from mid anteroseptal (72%) or mid inferoseptal (28%) segment at 23±5ms, spreading to basal posterolateral segment at 49±8ms from the start of QRS, in all but one case, where activation ended at basal inferoseptal segment (Fig. 1B). During CRT off, septal wall was activated 31±9ms and lateral wall 74±20ms after the beginning of QRS (p&amp;lt;0.01) (Fig. 1C), whereas during CRT on, septal wall was activated 41±11ms and lateral wall 38±7ms after the beginning of QRS (p=0.3) (Fig. 1D). Changing the pacing pole of the LV lead in one CRT patient also changed the start of mechanical activation in the lateral wall (Fig. 2). Conclusion Our findings comply with left ventricular activation as described in the literature and show that HFR STE could be a useful tool in defining the ablation target for arrhythmia treatment.

Echocardiography-Based Deep Learning Model to Differentiate Constrictive Pericarditis and Restrictive Cardiomyopathy

BackgroundConstrictive pericarditis (CP) is an uncommon but reversible cause of diastolic heart failure if appropriately identified and treated. However, its diagnosis remains a challenge for clinicians. Artificial intelligence may enhance the identification of CP. ObjectivesThe authors proposed a deep learning approach based on transthoracic echocardiography to differentiate CP from restrictive cardiomyopathy. MethodsPatients with a confirmed diagnosis of CP and cardiac amyloidosis (CA) (as the representative disease of restrictive cardiomyopathy) at Mayo Clinic Rochester from January 2003 to December 2021 were identified to extract baseline demographics. The apical 4-chamber view from transthoracic echocardiography studies was used as input data. The patients were split into a 60:20:20 ratio for training, validation, and held-out test sets of the ResNet50 deep learning model. The model performance (differentiating CP and CA) was evaluated in the test set with the area under the curve. GradCAM was used for model interpretation. ResultsA total of 381 patients were identified, including 184 (48.3%) CP, and 197 (51.7%) CA cases. The mean age was 68.7 ± 11.4 years, and 72.8% were male. ResNet50 had a performance with an area under the curve of 0.97 to differentiate the 2-class classification task (CP vs CA). The GradCAM heatmap showed activation around the ventricular septal area. ConclusionsWith a standard apical 4-chamber view, our artificial intelligence model provides a platform to facilitate the detection of CP, allowing for improved workflow efficiency and prompt referral for more advanced evaluation and intervention of CP.

Deep Learning–Enabled Assessment of Left Heart Structure and Function Predicts Cardiovascular Outcomes

BackgroundDeep learning interpretation of echocardiographic images may facilitate automated assessment of cardiac structure and function. ObjectivesWe developed a deep learning model to interpret echocardiograms and examined the association of deep learning–derived echocardiographic measures with incident outcomes. MethodsWe trained and validated a 3-dimensional convolutional neural network model for echocardiographic view classification and quantification of left atrial dimension, left ventricular wall thickness, chamber diameter, and ejection fraction. The training sample comprised 64,028 echocardiograms (n = 27,135) from a retrospective multi-institutional ambulatory cardiology electronic health record sample. Validation was performed in a separate longitudinal primary care sample and an external health care system data set. Cox models evaluated the association of model-derived left heart measures with incident outcomes. ResultsDeep learning discriminated echocardiographic views (area under the receiver operating curve >0.97 for parasternal long axis, apical 4-chamber, and apical 2-chamber views vs human expert annotation) and quantified standard left heart measures (R2 range = 0.53 to 0.91 vs study report values). Model performance was similar in 2 external validation samples. Model-derived left heart measures predicted incident heart failure, atrial fibrillation, myocardial infarction, and death. A 1-SD lower model-left ventricular ejection fraction was associated with 43% greater risk of heart failure (HR: 1.43; 95% CI: 1.23-1.66) and 17% greater risk of death (HR: 1.17; 95% CI: 1.06-1.30). Similar results were observed for other model-derived left heart measures. ConclusionsDeep learning echocardiographic interpretation accurately quantified standard measures of left heart structure and function, which in turn were associated with future clinical outcomes. Deep learning may enable automated echocardiogram interpretation and disease prediction at scale.

Sitting maneuver to uncover latent left ventricular outflow tract obstruction in patients without hypertrophic cardiomyopathy

BackgroundLeft ventricular outflow tract obstruction [LVOTO; pressure gradient (PG) ≥30 mmHg] is observed in some patients without hypertrophic cardiomyopathy (HCM), and it may develop especially in older patients without HCM (non-HCM). The aim of this study is to investigate if the Valsalva or an upright sitting maneuver can unveil latent LVOTO in patients with non-HCM. MethodsA total of 33 non-HCM patients with a late peaking or dagger-shaped pulsed Doppler waveform of the LVOT and PG <30 mmHg were included. The Doppler flow velocity of the LVOT was measured at rest, after the Valsalva and a sitting maneuver. Peak PG of ≥30 mmHg after either maneuver was defined as latent LVOTO. The angle between the left ventricular septum and the aorta in the parasternal long-axis view and the apical three-chamber view was measured. ResultsTwenty (61 %) of the 33 patients (mean age 74 ± 9 years) were diagnosed with latent LVOTO. Of these, five (25 %) patients were diagnosed after both the Valsalva and sitting maneuver, and 15 (75 %) were diagnosed only after the sitting maneuver. The latent LVOTO group had a significantly smaller angle than the no-LVOTO group between the ventricular septum and the aorta in the parasternal long axis views (107 ± 8° vs. 117 ± 8°, p < 0.01). ConclusionThe sitting maneuver is better than the Valsalva maneuver in unveiling latent LVOTO in older, non-HCM patients.

Right ventricular free wall and four-chamber longitudinal strain in relation to incident heart failure in the general population.

Right ventricular free wall (RVFWLS) and four-chamber longitudinal strain (RV4CLS) are associated with adverse events in various patient populations including patients with heart failure (HF). We sought to investigate the prognostic value of RVFWLS and RV4CLS for the development of incident HF in participants from the general population. Participants from the 5th Copenhagen City Heart Study (2011-2015) without known chronic ischaemic heart disease or HF at baseline were included. RVFWLS and RV4CLS were obtained using two-dimensional speckle-tracking echocardiography from the right ventricular (RV)-focused apical four-chamber view. The primary endpoint was incident HF. Among 2740 participants (mean age 54 ± 17 years, 42% male), 43 (1.6%) developed HF during a median follow-up of 5.5 years (IQR 4.5-6.3). Both RVFWLS and RV4CLS were associated with an increased risk of incident HF during follow-up independent of age, sex, hypertension, diabetes, body mass index and tricuspid annular plane systolic excursion (TAPSE), (HR 1.06, 95%CI 1.00-1.11, P = 0.034, per 1% absolute decrease and HR 1.14, 95%CI 1.05-1.23, P = 0.001, per 1% absolute decrease, respectively). Left ventricular ejection fraction (LVEF) modified the association between RV4CLS and incident HF (P for interaction = 0.016) such that RV4CLS was only of prognostic importance among those with LVEF < 55% (HR 1.21, 95%CI 1.11-1.33, P < 0.001 vs. HR 0.94, 95%CI 0.80-1.10, P = 0.43 in patients with LVEF ≥ 55%). In participants from the general population, both RVFWLS and RV4CLS were associated with a greater risk of incident HF independent of important baseline characteristics and TAPSE, and LVEF modified the relationship between RV4CLS and incident HF.

Weakly supervised video-based cardiac detection for hypertensive cardiomyopathy

IntroductionParameters, such as left ventricular ejection fraction, peak strain dispersion, global longitudinal strain, etc. are influential and clinically interpretable for detection of cardiac disease, while manual detection requires laborious steps and expertise. In this study, we evaluated a video-based deep learning method that merely depends on echocardiographic videos from four apical chamber views of hypertensive cardiomyopathy detection.MethodsOne hundred eighty-five hypertensive cardiomyopathy (HTCM) patients and 112 healthy normal controls (N) were enrolled in this diagnostic study. We collected 297 de-identified subjects’ echo videos for training and testing of an end-to-end video-based pipeline of snippet proposal, snippet feature extraction by a three-dimensional (3-D) convolutional neural network (CNN), a weakly-supervised temporally correlated feature ensemble, and a final classification module. The snippet proposal step requires a preliminarily trained end-systole and end-diastole timing detection model to produce snippets that begin at end-diastole, and involve contraction and dilatation for a complete cardiac cycle. A domain adversarial neural network was introduced to systematically address the appearance variability of echo videos in terms of noise, blur, transducer depth, contrast, etc. to improve the generalization of deep learning algorithms. In contrast to previous image-based cardiac disease detection architectures, video-based approaches integrate spatial and temporal information better with a more powerful 3D convolutional operator.ResultsOur proposed model achieved accuracy (ACC) of 92%, area under receiver operating characteristic (ROC) curve (AUC) of 0.90, sensitivity(SEN) of 97%, and specificity (SPE) of 84% with respect to subjects for hypertensive cardiomyopathy detection in the test data set, and outperformed the corresponding 3D CNN (vanilla I3D: ACC (0.90), AUC (0.89), SEN (0.94), and SPE (0.84)). On the whole, the video-based methods remarkably appeared superior to the image-based methods, while few evaluation metrics of image-based methods exhibited to be more compelling (sensitivity of 93% and negative predictive value of 100% for the image-based methods (ES/ED and random)).ConclusionThe results supported the possibility of using end-to-end video-based deep learning method for the automated diagnosis of hypertensive cardiomyopathy in the field of echocardiography to augment and assist clinicians.Trial registrationCurrent Controlled Trials ChiCTR1900025325, Aug, 24, 2019. Retrospectively registered.

Incidental Diagnosis of Left Pneumothorax Using a New Variant of the Lung Point Sign During Cardiac Ultrasound

BackgroundPneumothorax is a common issue in the intensive care unit and emergency department, often diagnosed using lung ultrasound. The absence of lung sliding and the presence of the lung point sign are characteristic findings for pneumothorax. We describe a case of left pneumothorax diagnosed incidentally while performing a cardiac ultrasound through a new variant of the lung point sign. Case ReportA 60-year-old patient with a medical history of diabetes, stroke, and right colon cancer underwent urgent surgical treatment for intestinal sub-occlusion. In the intensive care unit, the patient required mechanical ventilation due to shock unresponsive to fluid administration, and hemodynamic monitoring was performed using echocardiography. During systole in an apical four-chamber view, the abrupt vanishing of the heart was observed. When evaluating the tricuspid annular plane systolic excursion (TAPSE) using M-mode, the interposition of the stratosphere sign during mid-systole prevented the visualization of the TAPSE peak. Lung ultrasound revealed the absence of lung sliding and the presence of the lung point sign on the left side of the thorax, confirming the diagnosis of pneumothorax. A chest x-ray study further confirmed the diagnosis, and urgent drainage was performed. The patient showed improvement in hemodynamic and respiratory conditions and was successfully weaned from mechanical ventilation, and eventually discharged home. Why Should an Emergency Physician Be Aware of This?By incorporating the lung ultrasound findings, including this new variant of the lung point sign, into their diagnostic approach to pneumothorax, emergency physicians can promptly initiate appropriate intervention, such as chest tube insertion, leading to improved patient outcomes.