Apical View Research Articles

Serial Changes in Ventricular Strain in Symptomatic Obstructive Hypertrophic Cardiomyopathy Treated With Mavacamten: Insights From the VALOR-HCM Trial.

In severely symptomatic patients with obstructive hypertrophic cardiomyopathy, VALOR-HCM (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) demonstrated that mavacamten reduces the need for septal reduction therapy with sustained improvement in left ventricular (LV) outflow tract gradients and symptoms. Global longitudinal strain (GLS), a measure of regional myocardial function, is a more sensitive marker of systolic function. In VALOR-HCM, we assessed serial changes in LV and right ventricular (RV) strain. VALOR-HCM included 112 patients with symptomatic obstructive hypertrophic cardiomyopathy (mean, 60 years; 51% male; LV ejection fraction, 68%). Patients assigned to mavacamten at baseline continued the drug for 56 weeks (n=56) and those assigned to placebo (n=52) transitioned to mavacamten from weeks 16 to 56 (40-week exposure). LV-GLS and RV-GLS assessment was performed using a vendor-neutral software. Non-foreshortened apical (4-, 3-, and 2-chamber) views were used to obtain peak LV-GLS. RV focused 4-chamber view was used to calculate RV 4-chamber and free wall strain. A more negative strain value is favorable. At baseline, the mean LV-GLS, RV 4-chamber, and free wall strain values were -14.7%, -22.2%, and -16.8%, respectively (all worse than reported normal means). In the total study sample, LV-GLS significantly improved from baseline to week 56 (P=0.02). Twelve patients had transient reduction in LV ejection fraction (<50%) requiring temporary drug interruption (including 3 permanent discontinuations). The LV-GLS in this subgroup was worse at baseline versus total study population (-11.4%), with no significant worsening from baseline through week 56 (P=0.64). Both free wall and 4-chamber RV-GLS remained unchanged from baseline to week 56 (P=0.62 and P=0.56, respectively). In VALOR-HCM, treatment with mavacamten improved LV-GLS from baseline through week 56 (with no significant worsening of LV-GLS in patients with a reduction in LV ejection fraction ≤50%), suggesting a favorable long-term impact on regional LV systolic function. Additionally, there was no detrimental impact on RV systolic function. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04349072.

Effect of tafamidis on left atrial function of patients with transthyretin amyloid cardiomyopathy.

Transthyretin amyloid cardiomyopathy (ATTR-CM) is characterized by the functional and structural effects of amyloid infiltration, predominantly within the ventricles, causing biventricular wall thickening. Amyloid infiltration can be observed in the left atrium in ATTR-CM patients, but the association of left atrial (LA) myocardial function with cardiovascular events and of changes in LA myocardial function with tafamidis administration have not yet been clarified. Our aim was, therefore, to use speckle-tracking strain for investigating LA myocardial function in patients with ATTR-CM treated with tafamidis. We studied 55 patients with biopsy-proven ATTR-CM who had been treated with tafamidis (age: 76 ± 2years, male: 93%). For speckle-tracking analysis of LA myocardial function, the systolic LA strain (LA reservoir function) was defined for this study as LA myocardial function from the apical 4-chamber view. The primary endpoint was defined as a composite comprising cardiovascular death and/or heart failure hospitalization after tafamidis administration over a median follow-up period of 28 ± 4months. Patients with baseline LA strain < 8.6% (median value) experienced significantly more cardiovascular events than those without (log-rank P = 0.002). Moreover, LA strain in 26 patients worsened after tafamidis administration, and multivariate logistic regression analysis showed age, global longitudinal strain and relative apical longitudinal strain index were identified as independent determinants of deterioration of LA strain after tafamidis administration. In conclusion, baseline LA reservoir function is closely associated with cardiovascular events after tafamidis administration, and could be an additional parameter for the management of patients with ATTR-CM.

Surface morphology and chemical composition analysis of titanium dental implants using SEM and EDX.

The chemical content and surface morphology of titanium implants have a greater impact on the osseointegration characteristic of dental implants. Therefore this study was done to examine the surface morphology and chemical composition of commercially available titanium dental implants. (BioLine Dental Implants Series-single piece (A) and spiral implants (B)). The chemical composition was determined by the Energy Dispersive X-ray Spectroscopy (EDX) method and the surface morphology was performed by Scanning Electron Microscopy (SEM) method. The results for chemical composition of titanium implants using EDX method revealed that titanium (Ti) constitutes the major surface components on the plain and top land area of the single piece compressive implants which is 89.71 weight% and 71.55 weight % respectively. Iron (Fe)-66.60 weight % is considered as major element along with chromium (Cr)-18.34 weight %on the plain area of spiral implants and O (19.90 weight %) and Al (12.43 weight %) on the top land area of spiral implants. The surface morphology and impact of the manufacturing process on the implant surface using SEM method revealed that the similar surface irregularities with diameter ranging from 10 µm to 20 µm on the side view of the top land area and diameter of 10 µm on the side view of plain area for both the samples. Sample A showed some amorphous structures with grainy marks on the apical view whereas Sample B showed heavy grinding and shear marks on the apical view at diameter ranging from 10 µm to 20µm.

Impaired left ventricular function in lean women with PCOS: Insights from speckle tracking echocardiography

Aims: We aimed to conduct a study examining left ventricular function (LVEF) in lean women PCOS patients with speckle tracking echocardiography. Methods: The study included 60 patients diagnosed with PCOS and 30 healthy controls matched for age and body mass index. Morning fasting blood samples were collected to measure levels of glucose, insulin, high-sensitivity C-reactive protein (hs-CRP), and lipids. Left ventricular function (LVF) was evaluated using two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (3D-Echo). Global strain was assessed from three standard apical views using 2D-STE. Results: The hs-CRP levels in lean women with PCOS were significantly higher compared to the control group (2.34±1.07 vs. 1.13±0.54; p=0.01). The peak longitudinal strain values in the 2-chamber, 4-chamber, and long-axis views were lower in lean women with PCOS compared to the control group (15.9±1.2 vs. 19.4±1.2; p=0.01, 17.0±1.1 vs. 19.2±1.4; p=0.01, 16.3±1.3 vs. 19.2±1.5; respectively, p=0.01). According to the multiple regression model, global strain was independently associated with hs-CRP (β=0.31, p=0.04), the ratio of early diastolic mitral inflow velocity (E) to early diastolic annular velocity (E/E’ ratio) (β=0.33, p=0.01), and ejection fraction (EF) (β=0.35, p=0.01). Conclusion: Our findings reveal that lean women with PCOS exhibit significantly higher levels of high-sensitivity C-reactive protein (hs-CRP) compared to healthy controls. Furthermore, the peak longitudinal strain values across multiple cardiac views were notably lower in the PCOS group, suggesting impaired left ventricular function. These results highlight the importance of monitoring cardiovascular health in lean women with PCOS, as they are at an increased risk of developing left ventricular dysfunction despite their lean body mass index.

Echocardiographic image quality deteriorates with the severity of cardiogenic shock

BackgroundTransthoracic echocardiography (TTE) is the primary tool for assessing left ventricular (LV) function in cardiogenic shock (CS). However, inadequate image quality often hinders it. In this retrospective study, we investigated factors associated with LV image quality in patients admitted to the intensive care unit (ICU) with ischemic CS.ResultsTwo critical care physicians accredited in echocardiography independently reviewed the TTEs of 100 patients admitted to our tertiary cardiac ICU with ST-elevation myocardial infarction complicated by CS between October 2016 and September 2019. Endocardial border definition (EBD) was graded for each myocardial segment of the apical 4-chamber and 2-chamber views using a conventional scoring system (1 = good, 2 = suboptimal, 3 = poor, and 4 = not possible). The biplane EBD index (EBDi) was calculated by averaging all segments from both views. An average EBDi of both observers was correlated with clinical and echocardiographic parameters. The median age was 62 years [54, 73], and 78% were males. LV ejection fraction and cardiac index (CI) medians were 29% [20, 35] and 1.93 l/min/m2 [1.40, 2.51], respectively. The median biplane EBDi was nearly suboptimal (1.833 [1.542, 2.083]). There was no correlation between EBDi and age, sex, or body mass index. However, biplane EBDi demonstrated statistically significant correlations with PaO2 (r2 = 0.066, p = 0.01), mean arterial pressure (MAP, r2 = 0.055, p = 0.03), CI (r2 = 0.105, p < 0.01), tricuspid annulus systolic velocity (RV S’, r2 = 0.092, p = 0.01), and tricuspid regurge maximum velocity (TR Vmax, r2 = 0.067, p = 0.01). In a multivariate model, only CI correlated independently with EBDi (r2 = 0.105, p < 0.01). The biplane EBDi predicted CI (area under the curve (AUC) 0.70, p = 0.001) with good sensitivity (71%) and reasonable specificity (61%).ConclusionsThe study suggests that in patients admitted to the ICU with ischemic CS, LV image quality by TTE deteriorates with the severity of shock, as indicated by CI.

High-Throughput Deep Learning Detection of Mitral Regurgitation.

Diagnosis of mitral regurgitation (MR) requires careful evaluation by echocardiography with Doppler imaging. This study presents the development and validation of a fully automated deep learning pipeline for identifying apical 4-chamber view videos with color Doppler echocardiography and detecting clinically significant (moderate or severe) MR from transthoracic echocardiograms. A total of 58 614 transthoracic echocardiograms (2 587 538 videos) from Cedars-Sinai Medical Center were used to develop and test an automated pipeline to identify apical 4-chamber view videos with color Doppler across the mitral valve and then assess MR severity. The model was tested internally on a test set of 1800 studies (80 833 videos) from Cedars-Sinai Medical Center and externally evaluated in a geographically distinct cohort of 915 studies (46 890 videos) from Stanford Healthcare. In the held-out Cedars-Sinai Medical Center test set, the view classifier demonstrated an area under the curve (AUC) of 0.998 (0.998-0.999) and correctly identified 3452 of 3539 echocardiography videos as having color Doppler information across the mitral valve (sensitivity of 0.975 [0.968-0.982] and specificity of 0.999 [0.999-0.999] compared with manually curated videos). In the external test cohort from Stanford Healthcare, the view classifier correctly identified 1051 of 1055 manually curated videos with color Doppler information across the mitral valve (sensitivity of 0.996 [0.990-1.000] and specificity of 0.999 [0.999-0.999]). In the Cedars-Sinai Medical Center test cohort, MR moderate or greater in severity was detected with an AUC of 0.916 (0.899-0.932) and severe MR was detected with an AUC of 0.934 (0.913-0.953). In the Stanford Healthcare test cohort, the model detected MR moderate or greater in severity with an AUC of 0.951 (0.924-0.973) and severe MR with an AUC of 0.969 (0.946-0.987). In this study, a novel automated pipeline for identifying clinically significant MR from full transthoracic echocardiography studies demonstrated excellent performance across large numbers of studies and across multiple institutions. Such an approach has the potential for automated screening and surveillance of MR.

Assessment of an Artificial Intelligence Tool for Estimating Left Ventricular Ejection Fraction in Echocardiograms from Apical and Parasternal Long-Axis Views.

This work aims to evaluate the performance of a new artificial intelligence tool (ExoAI) to compute the left ventricular ejection fraction (LVEF) in echocardiograms of the apical and parasternal long axis (PLAX) views. We retrospectively gathered echocardiograms from 441 individual patients (70% male, age: 67.3 ± 15.3, weight: 87.7 ± 25.4, BMI: 29.5 ± 7.4) and computed the ejection fraction in each echocardiogram using the ExoAI algorithm. We compared its performance against the ejection fraction from the clinical report. ExoAI achieved a root mean squared error of 7.58% in A2C, 7.45% in A4C, and 7.29% in PLAX, and correlations of 0.79, 0.75, and 0.89, respectively. As for the detection of low EF values (EF < 50%), ExoAI achieved an accuracy of 83% in A2C, 80% in A4C, and 91% in PLAX. Our results suggest that ExoAI effectively estimates the LVEF and it is an effective tool for estimating abnormal ejection fraction values (EF < 50%). Importantly, the PLAX view allows for the estimation of the ejection fraction when it is not feasible to acquire apical views (e.g., in ICU settings where it is not possible to move the patient to obtain an apical scan).

Automatic tablet-based monoplane quantification of stroke volume and left ventricular ejection fraction: A comparative assessment against computer-based biplane and monoplane tools.

Point-of-care cardiovascular left ventricle ejection fraction (LVEF) quantification is established, but automatic tablet-based stroke volume (SV) quantification with handheld ultrasound (HAND) devices is unexplored. We evaluated a tablet-based monoplane LVEF and LV volume quantification tool (AutoEF) against a computer-based tool (Tomtec) for LVEF and SV quantification. Patients underwent HAND scans, and LVEF and SV were quantified using AutoEF and computer-based software that utilized either apical four-chamber views (Auto Strain-monoplane [AS-mono]) or both apical four-chamber and apical two-chamber views (Auto Strain-biplane [AS-bi]). Correlation and Bland-Altman analysis were used to compare AutoEF with AS-mono and AS-bi. Out of 43 participants, eight were excluded. AutoEF showed a correlation of.83 [.69:.91] with AS-mono for LVEF and.68 [.44:.82] for SV. The correlation with AS-bi was.79 [.62:.89] for LVEF and.66 [.42:.81] for SV. The bias between AutoEF and AS-mono was 4.88% [3.15:6.61] for LVEF and 17.46mL [12.99:21.92] for SV. The limits of agreement (LOA) were [-5.50:15.26]% for LVEF and [-8.02:42.94] mL for SV. The bias between AutoEF and AS-bi was 6.63% [5.31:7.94] for LVEF and 20.62mL [16.18:25.05] for SV, with LOA of [-1.20:14.47]% for LVEF and [-4.71:45.94] mL for SV. LVEF quantification with AutoEF software was accurate and reliable, but SV quantification showed limitations, indicating non-interchangeability with neither AS-mono nor AS-bi. Further refinement of AutoEF is needed for reliable SV quantification at the point of care.

Artificial intelligence-derived left ventricular strain in echocardiography in patients treated with chemotherapy

Global longitudinal strain (GLS) is an echocardiographic measure to detect chemotherapy-related cardiovascular dysfunction. However, its limited availability and the needed expertise may restrict its generalization. Artificial intelligence (AI)-based GLS might overcome these challenges. Our aims are to explore the agreements between AI-based GLS and conventional GLS, and to assess whether the agreements were influenced by expertise levels, cardiac remodeling and cardiovascular diseases/risks. Echocardiographic images in the apical four-chamber view of left ventricle were retrospectively analyzed based on AI-based GLS in patients treated with chemotherapy, and correlation between AI-based GLS (Caas Qardia, Pie Medical Imaging) and conventional GLS (Vivid E9/VividE95, GE Healthcare) were assessed. The agreement between unexperienced physicians (“GLS beginner”) and experienced echocardiographer were also assessed. Among 94 patients (mean age 69 ± 12 years, 73% female), mean left ventricular ejection fraction was 64 ± 6%, 14% of patients had left ventricular hypertrophy, and 21% had left atrial enlargement. Mean GLS was − 15.9 ± 3.4% and − 19.0 ± 3.7% for the AI and conventional method, respectively. There was a moderate correlation between these methods (rho = 0.74; p < 0.01), and bias was − 3.1% (95% limits of agreement: -8.1 to 2.0). The reproducibility between GLS beginner and an experienced echocardiographer was numerically better in the AI method than the conventional method (inter-observer agreement = 0.82 vs. 0.68). The agreements were consistent across abnormal cardiac structure and function categories (p-for-interaction > 0.10). In patients treated with chemotherapy. AI-based GLS was moderately correlated with conventional GLS and provided a numerically better reproducibility compared with conventional GLS, regardless of different levels of expertise.

TTE apical 2-chamber view suggested mitral valve vegetation formation before treatment.

TTE apical 2-chamber view suggested mitral valve vegetation formation before treatment.

TTE apical two-chamber view suggested the disappearance of mitral valve vegetation after treatment.

TTE apical two-chamber view suggested the disappearance of mitral valve vegetation after treatment.

Deep Learning for Echo Analysis, Tracking, and Evaluation of Mitral Regurgitation (DELINEATE-MR).

Artificial intelligence, particularly deep learning (DL), has immense potential to improve the interpretation of transthoracic echocardiography (TTE). Mitral regurgitation (MR) is the most common valvular heart disease and presents unique challenges for DL, including the integration of multiple video-level assessments into a final study-level classification. A novel DL system was developed to intake complete TTEs, identify color MR Doppler videos, and determine MR severity on a 4-step ordinal scale (none/trace, mild, moderate, and severe) using the reading cardiologist as a reference standard. This DL system was tested in internal and external test sets with performance assessed by agreement with the reading cardiologist, weighted κ, and area under the receiver-operating characteristic curve for binary classification of both moderate or greater and severe MR. In addition to the primary 4-step model, a 6-step MR assessment model was studied with the addition of the intermediate MR classes of mild-moderate and moderate-severe with performance assessed by both exact agreement and ±1 step agreement with the clinical MR interpretation. A total of 61 689 TTEs were split into train (n=43 811), validation (n=8891), and internal test (n=8987) sets with an additional external test set of 8208 TTEs. The model had high performance in MR classification in internal (exact accuracy, 82%; κ=0.84; area under the receiver-operating characteristic curve, 0.98 for moderate or greater MR) and external test sets (exact accuracy, 79%; κ=0.80; area under the receiver-operating characteristic curve, 0.98 for moderate or greater MR). Most (63% internal and 66% external) misclassification disagreements were between none/trace and mild MR. MR classification accuracy was slightly higher using multiple TTE views (accuracy, 82%) than with only apical 4-chamber views (accuracy, 80%). In subset analyses, the model was accurate in the classification of both primary and secondary MR with slightly lower performance in cases of eccentric MR. In the analysis of the 6-step classification system, the exact accuracy was 80% and 76% with a ±1 step agreement of 99% and 98% in the internal and external test set, respectively. This end-to-end DL system can intake entire echocardiogram studies to accurately classify MR severity and may be useful in helping clinicians refine MR assessments.

Echocardiogram by apical-subcostal protocol in prone position during invasive mechanical ventilation in cardiovascular intensive care unit

AimsTo evaluate the feasibility of a transthoracic echocardiogram using an apical-subcostal protocol in invasive mechanical ventilation (IMV) and prone position.MethodsProspective study of adults who required a prone position during IMV. A pillow was placed only under the left hemithorax in the prone position to elevate and ease the apical and subcostal windows. A critical care cardiologist (prone group) acquired and evaluated the images using the apical-subcostal protocol. Besides, we used ambulatory echocardiograms performed as a comparative group (supine group).Results86 patients were included, 43 in the prone and 43 in the supine. In the prone group, the indication to perform an echocardiogram was hemodynamic monitoring. All patients were ventilated with protective parameters, and the mean end-expiratory pressure was 10.6 cmH2O. The protocol was performed entirely in 42 of 43 patients in the prone group because one patient did not have any acoustic window. In the 43 patients in the prone group analyzed and compared to the supine group, global biventricular function was assessed in 97.7% (p = 1.0), severe heart valve disease in 88.4% (p = 0.055), ruled out of the presence of pulmonary hypertension in 76.7% (p = 0.80), pericardial effusion in 93% (p = 0.12), and volume status by inferior vena cava in 93% (p = 0.48). Comparing prone versus supine position, a statistical difference was found when evaluating the left ventricle apical 2-chamber view (65.1 versus 100%, p < 0.01) and its segmental function (53.4 versus 100%, p < 0.01).ConclusionThe echocardiogram using an apical-subcostal protocol is feasible in patients in the IMV and prone position.Graphical

Effect of Ciprofol on Left Ventricular Myocardial Strain and Myocardial Work in Children Undergoing Cardiac Surgery: A Single-center Double-blind Randomized Noninferiority Study

ObjectiveTo compare the effect of ciprofol and propofol on left ventricular (LV) systolic function and myocardial work by noninvasive speckle-tracking echocardiography (STE) in children undergoing surgical repair of atrial septal defect (ASD) or ventricular septal defect (VSD). DesignSingle-center double-blind randomized non-inferiority study. SettingAt a tertiary care center affiliated to Shanghai Jiao Tong University, China. ParticipantsOne hundred and twelve children aged 1 month to 16 years old undergoing ASD or VSD surgery with cardiopulmonary bypass. InterventionsOne hundred and twelve children were allocated randomly into receiving ciprofol (n = 67) and propofol (n = 45) in a 1.5:1 ratio. Ciprofol or propofol were IV infused at loading doses of 0.4 mg/kg or 2.0 mg/kg respectively over 30 seconds depending on the physical condition of each patient. When the bispectral index was maintained between 45 - 55 after induction, transthoracic echocardiography including apical two-chamber, three-chamber and four-chamber views were collected at bedside. Measurements and Main ResultsOf total 112 patients enrolled, 104 completed the study. The global longitudinal strain (GLS) of ciprofol and propofol groups after anesthesia was -17.3% (95% CI, -18.0% to -16.6%) and -17.8% (-18.7 to -17.0%) in the full analysis set (FAS) and -17.5% (95% CI, -18.2% to -16.9%) and -17.8% (-18.7% to -17.0%) in the per-protocol set (PPS) respectively. The noninferiority margin was set as 2% and confirmed with a lower limit of two-sided 95% CI for the inter-group difference of 1.58% and 1.34% in the FAS and PPS. There were no significant differences between two groups in LV systolic and diastolic function and myocardial work indices. Postoperative vasoactive-inotropic score, NT-proBNP, duration of mechanical ventilation, length of stay in cardiac intensive care unit and hospital were also comparable between two groups (all p > 0.05). ConclusionsCiprofol did not show different effect from propofol on myocardial function and postoperative outcomes. Furtherly on sensitive cardiac systole marker GLS, ciprofol had noninferiority to propofol. Ciprofol might be alternative solution for cardiac anesthesia in CHD children with mild lesion.

Trajectory of Diastolic Function after Heart Transplantation as Assessed by Left Atrial Deformation Analysis.

Diastolic dysfunction (DD) is a prevalent and clinically significant complication after heart transplantation (HTX). We aimed to characterize the diastolic function of HTX recipients with both short-term and long-term follow-ups by applying left atrial (LA) deformation analysis. We consecutively enrolled and followed up with 33 HTX patients. Three assessments were performed one month, 3-5 months, and 3-5 years after surgery. Beyond conventional echocardiographic measurements, apical four-chamber views optimized for speckle tracking analysis were acquired and post-processed by dedicated software solutions (TomTec AutoStrain LA and LV). Left atrial phasic functions were characterized by reservoir, conduit, and contraction strains. We categorized diastolic function according to current guidelines (normal diastolic function, indeterminate, DD). At the first assessment, nine (27%) patients were in the DD category, and eleven (33%) were indeterminate. At the second assessment, only one patient (3%) remained in the DD category and six (18%) were indeterminate. At the third assessment, 100% of patients were categorized as having normal diastolic function. LA reservoir strain gradually increased over time. LA contraction strain significantly improved from the second to the third assessment. We found a correlation between the LA reservoir strain and NT-proBNP (r = 0.40, p < 0.05). DD is prevalent immediately after HTX but rare until the end of the first postoperative quarter. Speckle tracking analysis enables the characterization of LA phasic functions that may reflect both short- and long-term changes in diastolic function and correlate with NT-proBNP.

Structural and functional cardiac parameters across occupations: a cross-sectional study in differing work environments

Previous investigations have highlighted notable variations in cardiovascular risk indicators associated with various professional categories. However, only a few studies have examined structural and functional cardiac parameters using echocardiography within distinct occupational groups. Hence, this study endeavored to assess cardiac structural and functional parameters in three additional occupations: firefighters (FFs), police officers (POs), and office workers (OWs). This prospective study encompassed 197 male participants (97 FFs, 54 POs, and 46 OWs) from Germany. All participants underwent 2D and Doppler echocardiography in resting conditions; standard parasternal and apical axis views were employed to evaluate structural (diastolic and systolic) and functional (systolic and diastolic function, and strain) cardiac parameters. All three occupational groups exhibited a tendency towards septal hypertrophy. Notably, OWs exhibited the largest diastolic interventricular septum diameter (IVSd), at 1.33 ± 0.25 cm. IVSd significantly varied between POs and OWs (p = 0.000) and between POs and FFs (p = 0.025). Additionally, during diastole a substantially larger left ventricular posterior wall diameter (LVPWd) was observed in OWs compared to FFs (p = 0.001) and POs (p = 0.013). The left ventricular diastolic cavity diameter (LVIDd) and the left ventricular systolic cavity diameter (LVIDs) were significantly higher in POs than they were in FFs (LVIDd: p = 0.001; LVIDs: p = 0.009), and the LVIDd was notably higher in FFs (p = 0.015) and POs compared to OWs (p = 0.000). FFs exhibited significantly better diastolic function, indicated by higher diastolic peak velocity ratios (MV E/A ratio) and E/E’ ratios, compared to POs (E/A ratio: p = 0.025; E/E’ ratio: p = 0.014). No significant difference in diastolic performance was found between OWs and FFs. Significantly higher E’(lateral) values were noted in POs compared to FFs (p = 0.003) and OWs (p = 0.004). Ejection fraction did not significantly differ among FFs, POs, and OWs (p > 0.6). The left ventricular mass (LV Mass) was notably higher in POs than it was in FFs (p = 0.039) and OWs (p = 0.033). Strain parameter differences were notably improved in two- (p = 0.006) and four-chamber (p = 0.018) views for FFs compared to POs. Concentric remodeling was the predominant change observed in all three occupational groups. Significant differences in the presence of various forms of hypertrophy were observed in FFs, POs, and OWs (exact Fisher test p-values: FFs vs. OWs = 0.021, POs vs. OWs = 0.002). OWs demonstrated notably higher rates of concentric remodeling than FFs did (71.77% vs. 47.9%). This study underscores disparities in both functional and structural parameters in diverse occupational groups. Larger prospective studies are warranted to investigate and delineate differences in structural and functional cardiac parameters across occupational groups, and to discern their associated effects and risks on the cardiovascular health of these distinct professional cohorts.

Temporal variability of electromechanical-window negativity in patients with inherited long-QT syndrome or drug-induced QT prolongation: relation to torsades de pointes

Abstract Background Electromechanical window (EMW) negativity is a novel parameter that identifies long-QT syndrome (LQTS) patients at increased arrhythmia risk. Whether the EMW remains stable or alters, especially close to arrhythmic events, is unknown. Purpose To study temporal variability of the EMW in controls and in patients with LQTS or drug-induced QT prolongation (di-QTprol), in relation to the timing of torsades de pointes (TdP) or ventricular fibrillation (VF). Methods In a retrospective cohort study with 5 participating centers, we assessed the EMW (ms) at 2 or 3 timepoints (if applicable, one of them close to TdP/VF) from cw-Doppler echocardiography in the apical long-axis view and concomitant ECG. EMW was calculated by subtracting the QT time from the aortic-valve closure time measured from QRS onset (surrogate of mechanical systole). Data are shown as mean±SD or median (25th to 75th percentile). Results Forty patients (75% female, 43±18 years old) were included: 8 controls, 27 LQTS (10 symptomatic: 9 TdP, 1 VF), and 5 di-QTprol (all TdP). LQTS genotypes were LQT1 (n=11), LQT2 (n=6), LQT3 (n=7), LQT7 (n=2), and genotype-negative (n=1). Overall, 67% of LQTS patients and 20% of di-QTprol were treated with β-blockers. Baseline QTc was 409±32 ms in controls, 444±32 ms in asymptomatic LQTS, 491±41 ms in symptomatic LQTS, and 498±49 ms in di-QTprol. Baseline EMW was 6±14 ms in controls, -12±29 ms in asymptomatic LQTS, -52±16 ms in symptomatic LQTS, and -5±69 ms in di-QTprol. Over years of follow-up, EMW remained stable in controls (8±10 ms; Fig. 1A) and the asymptomatic LQTS group (-17±20 ms; Fig. 1B). In LQTS patients with TdP/VF, EMW (baseline measured at -534 (-962 to -143) days before arrhythmia) had become profoundly more negative, -127±42 ms, (p=0.01 vs. baseline) at 1 (0 to 5) days after the arrhythmia and returned to basal values, -52±18 ms, (p=0.005) after 722 (155 to 3100) days (Fig. 1C). There was a significant correlation between time-to-event and EMW negativity (r=0.72, p&amp;lt;0.0001), indicating stronger EMW negativity when measured closer to TdP/VF. For the di-QTprol patients (n=2 amiodarone; n=2 escitalopram; n=1 sotalol) a trend towards more exaggerated EMW negativity was observed: from baseline (at -19 (-785 to -13) days before the event) to -125±33 ms (p=0.08 vs. baseline) at 1 (1 to 5) days after TdP (Fig. 1D). Again, significant correlation was found between time-to-event and EMW negativity (r=0.6, p=0.03). Conclusion Episodes of electrical instability in patients with LQTS or di-QTprol are associated with profound but reversible exaggeration of EMW negativity. If also present just prior to TdP/VF (as in experimental models of torsadogenic di-QTprol and anecdotal LQTS cases), imminent ventricular arrhythmias may be anticipated as electromechanical reciprocity may contribute to arrhythmogenesis.Figure 1Graphical Abstract

A NEGLECTED RARE DISORDER: IGG4 RELATED DISEASE

Abstract IgG4–related disease (IgG4–RD) is an autoimmune disorder characterized by infiltration of plasma cells with IgG4. Almost any organ could be affected. Common presentations include lung manifestation, autoimmune pancreatitis, retroperitoneal fibrosis and tubulointerstitial nephritis. Cardiovascular involvement is less frequent. Corticosteroids are first line therapy, with or without anti–rheumatic drugs. Long–term prognosis of IgG4–RLD remains unknown. We present the case of a 65–years old woman, with a previuos diagnosis of IgG4–RD with mediastinal involvement. In the meantime she was recovered for pyelonephritis with high fever and positive blood coltures (S. hominis). We were called to perform a transthoracic echocardiogram to rule out infective endocarditis. The exam showed normal size of cardiac chambers, normal biventricular systolic function, absence of relevant valvular disease. In apical view we noticed a hyperechogenic ovalar imagine in the right atrium, not visible in all the projections. A first differential diagnosis included a mass with site of implantation at the top of the right atrium or something external but contiguous to heart structures. To clear this doubt the patient performed a thoracic CT with stunning results. The CT highlighted parietal encasement of chardiac structures and, particularly, of the superior vena cava at the confluence in right atrium, explaining the image we saw with transthoracic echo. The exam also showed encasement of ascending aorta, aortic arch and descending aorta with maximum thickness of 18 mm. CT also reported encasement of right pulmonary arthery. The CT highlighted a progression of the disease with indication to more aggressive therapy. In fact IgG4–RD of the cardiovascular system results in serious complications that need to be recognized and treated. Aortic involvement in IgG4–RD is extremely rare and tipically affects the infrarenal abdominal aorta. Cardiovascular IgG4–RD could also lead to aortitis, medium–vessel arteritis, pulmonary vascular disease, phlebitis, valvulopathy, pericarditis and myocardial disease. These forms of Igg4–RD are often underdiagnosed as clinical presentations is similar to cardiovascular disease due to more common aetiologies. Regarding our case the patient began methotrexate based on the results of the CT. This was a really interesting case for our working group to deepen this little–known disease. “The eyes see only what the mind is prepared to comprehend”.

Exploring heart dissection techniques for enhancing anatomical education: a pilot study to replicate transthoracic echocardiography.

For novice learners, converting two-dimensional (2D) images of echocardiography to three-dimensional (3D) cardiac structures is deemed challenging. This study aimed to develop an accurate dissection method of the heart to reproduce the transthoracic echocardiographic views on cadavers and elucidate new educational methods in human anatomy dissection courses. A total of 18 hearts were used in this study. After reflecting the anterior thoracic wall inferiorly, the hearts were excised from embalmed cadavers. Thereafter, three landmarks were set on the heart for each plane of the incision, and the hearts were incised to observe the three different echocardiographic views, which include the apical four-chamber view (A4C), parasternal long axis (PLAX) view, and parasternal short axis (PSAX) view at the papillary muscle level. If all structures for observation during routine echocardiography are clearly observed in each view, a successful incision is considered. All procedures and incisions were performed by the medical students. After a successful incision, hearts were returned to the original position in the pericardial sac for further observation. The success rates of incision for each view were 83.3% (5/6 success cases), 83.3% (5/6 success cases), and 66.7% (4/6 success cases) in the A4C view, PLAX view, and PSAX view at the papillary muscle level, respectively. This dissection method could probably be employed to reproduce transthoracic echocardiographic views on cadaveric hearts, which is beneficial for novice learners for a deeper understanding of the anatomy.

An Innovative Apical-4-Chamber-long-axis Imaging Approach Precisely Tracks Progressive Deterioration of Mouse Ventricles, Atria, and Atrioventricular Valves

Transthoracic echocardiography stands as the primary non-invasive method for cardiac function evaluation in clinical settings. It’s widely used to assess chamber sizes, heart wall integrity, as well as the hemodynamic performance of the left ventricle (LV), right ventricle (RV), atria, and valves. However, applying comprehensive echocardiography assessments to mice has been challenging, primarily due to diffculties in obtaining on-axis apical 4-chamber views; most mouse studies have thus been restricted to evaluating the LV using short-axis M-mode assays. To overcome this limitation, we’ve recently developed a novel methodology to consistently obtain high-quality apical 4-chamber-long-axis (A4CLAX) view images of mouse heart. This advancement permits a range of clinically relevant functional assessments, including Long Axis Biplane (LAX-BP) assay, which has been shown to surpasses M-mode in estimating LV function. In this study, we delve into the breadth of comprehensive echocardiography assessments made possible for mice through the A4CLAX imaging approach. We performed a severe transverse aortic constriction (TAC) surgery on mice and monitored the pathological development in their hearts post-surgery. Alongside the expected hypertrophy, the LAX-BP assay revealed LV volumetric dilation as early as 1-week after TAC surgery Indicative of decompensated heart failure; however, m-mode was not able to pick up on this early dilation due to its lack of longitudinal assessment and inconsistent measurements of EDV and ESV. The apical 4 chamber view significantly improved the consistency and reliability of trans mitral and pulmonary vein doppler recordings and enabled us to reliably estimate the pressure relationships of the LV and Left Atrial (LA) pressure, which is consistent with the LAX-BP detected LV decompensation. Additionally, the high clarity of the 4 chamber images achieved improved visualization of both mitral and tricuspid valve leaflets. This allowed more precise characterization of valvular issues, including mitral regurgitation caused by LV dilatation, as well as identification of less common pathological occurrences like desynchronization of the tricuspid and mitral valve opening. A speckle tracking assay of the Right ventricle (RV) showed that a delayed contraction of the lateral apical RV wall caused the tricuspid valve to not open during the early filling phase, but rather at the atrial kick, leading to this valve desynchrony. This delayed contraction indicates a possible elevation of pulmonary pressure, as evidenced by pulmonary vein doppler indices and the analysis of pulmonary congestion. In conclusion, the innovative A4CLAX imaging technique revolutionizes murine heart analysis, bringing it in line with clinical echocardiography standards allowing for a whole heart analysis approach. It sensitively identifies subtle anomalies, providing a precise characterization of cardiac remodeling and disease progression in mouse hearts. This study has been supported by grants NIH-R01HL139006 and R21OD031965. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.