Apical View Research Articles

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<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.

Right heart strain in arrhythmogenic right ventricular cardiomyopathy: implications for cardiovascular outcome.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by progressive myocardial dysfunction and associated with an increased risk of major cardiovascular (CV) events. To determine right heart strain (ventricular and atrial global longitudinal strain (RVGLS and RAGLS) in patients with definite ARVC and its association with adverse events during follow-up. RVGLS and RAGLS were analysed in focused right heart apical views from 70 patients using TomTec ImageArena and association with a composite endpoint was determined (sustained ventricular arrhythmia and cardiovascular death). Over a median follow-up duration of 4.9 years, 26 (37%) patients met the endpoint. RVGLS was significantly impaired in the event group (-11.5 [-13.3 to -10.2] %) vs. the no-event group (-15.8 [-17.1 to -14.5] %, P < 0.001), and so was RAGLS (22.8 [21.4-27.4] % vs. 31.5 [25.1-39.6] %, respectively, P < 0.001). In Cox regression, RVGLS (HR 1.36, P < 0.001) and RAGLS (HR 0.92, P = 0.002) were associated with a higher risk of adverse events. In multivariable Cox regression models, RVGLS and RAGLS remained independent of and were incremental to age, gender, and conventional RV parameters, and model fitness was improved when RVGLS and RAGLS were applied together rather than alone. RVGLS and RAGLS are more impaired in patients with adverse events and associated with adverse events independent of age, gender, and conventional RV parameters. When RVGLS and RAGLS are applied together, prediction models are improved suggesting that right heart strain may form part of the echocardiographic routine protocol in patients with ARVC.

Pulmonary Transit Time Assessment by CEUS in Healthy Rabbits: Feasibility, and the Effects of UCAs Dilution Concentration.

To evaluate the inter-observer variability and the intra-observer repeatability of pulmonary transit time (PTT) measurement using contrast-enhanced ultrasound (CEUS) in healthy rabbits, and assess the effects of dilution concentration of ultrasound contrast agents (UCAs) on PTT. Thirteen healthy rabbits were selected, and five concentrations UCAs of 1:200, 1:100, 1:50, 1:10, and 1:1 were injected into the right ear vein. Five digital loops were obtained from the apical 4-chamber view. Four sonographers obtained PTT by plotting the TIC of right atrium (RA) and left atrium (LA) at two time points (T1 and T2). The frame counts of the first appearance of UCAs in RA and LA had excellent inter-observer agreement, with intra-class correlations (ICC) of 0.996, 0.988, respectively. The agreement of PTT among four observers was all good at five different concentrations, with an ICC of 0.758-0.873. The reproducibility of PTT obtained by four observers at T1 and T2 was performed well, with ICC of 0.888-0.961. The median inter-observer variability across 13 rabbits was 6.5% and the median variability within 14 days for 4 observers was 1.9%, 1.7%, 2.2%, 1.9%, respectively; The PTT of 13 healthy rabbits is 1.01 ± 0.18 second. The difference of PTT between five concentrations is statistically significant. The PTT obtained by a concentration of 1:200 and 1:100 were higher than that of 1:1, while there were no significantly differences in PTT of a concentration of 1:1, 1:10, and 1:50. PTT measured by CEUS in rabbits is feasible, with excellent inter-observer and intra-observer reliability and reproducibility, and dilution concentration of UCAs influences PTT results.

Timing and Patient Position During Cuff Blood Pressure Measurement Affect Myocardial Work Parameters Measured by Echocardiography

Although cuff blood pressure measurement is a critical parameter to calculate myocardial work noninvasively, there is no recommendation about when and how to measure it. Accordingly, we sought to evaluate the effects of the timing during the echo study and the patient's position on the scanning bed during the cuff blood pressure measurement on myocardial work parameter calculations. One hundred one consecutive patients (44 women, 66±14years) undergoing clinically indicated echocardiography were prospectively enrolled. During the echocardiographic study, we measured the cuff blood pressure 4 times, using a fully automatic digital blood pressure monitor applied to the right and left arm in the same position throughout the study: BP1, before the start of the echo study, with the patient lying in the supine position; BP2, after positioning the patients on their left side to start the echo study; BP3, at the time of the acquisition of the 3 apical views (4- and 2-chamber and long-axis) used to measured left ventricular global longitudinal strain; and BP4, at the end of the echo study with the patient again in the supine position. Systolic blood pressureat BP1 was 147±21mm Hg. Between BP1 and BP2, it dropped by 17±9mm Hg (P<.05). Systolic blood pressure at BP3 was significantly lower than BP2 (130±20mm Hg vs 122±18mm Hg, P<.05), and at BP4 was significantly lower than at BP1 (-9 ± 13mm Hg, P<.05). The average global longitudinal strain was -16%±3%. Accordingly, the global work index was 1,929±441mm Hg% at BP1, dropped to 1,717±421 at BP2, decreased to 1,602±351mm Hg% at BP3, and increased to 1,815±386mm Hg% at BP4 (P<.001). The timing during the echocardiography study and the patient's position on the scanning bed are critical determinants of the measured cuff systolic blood pressure and the resulting values of myocardial work parameters.

Deep learning to assess right ventricular ejection fraction from two-dimensional echocardiograms in precapillary pulmonary hypertension.

Precapillary pulmonary hypertension (PH) is characterized by a sustained increase in right ventricular (RV) afterload, impairing systolic function. Two-dimensional (2D) echocardiography is the most performed cardiac imaging tool to assess RV systolic function; however, an accurate evaluation requires expertise. We aimed to develop a fully automated deep learning (DL)-based tool to estimate the RV ejection fraction (RVEF) from 2D echocardiographic videos of apical four-chamber views in patients with precapillary PH. We identified 85 patients with suspected precapillary PH who underwent cardiac magnetic resonance imaging (MRI) and echocardiography. The data was divided into training (80%) and testing (20%) datasets, and a regression model was constructed using 3D-ResNet50. Accuracy was assessed using five-fold cross validation. The DL model predicted the cardiac MRI-derived RVEF with a mean absolute error of 7.67%. The DL model identified severe RV systolic dysfunction (defined as cardiac MRI-derived RVEF<37%) with an area under the curve (AUC) of.84, which was comparable to the AUC of RV fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) measured by experienced sonographers (.87 and.72, respectively). To detect mild RV systolic dysfunction (defined as RVEF ≤ 45%), the AUC from the DL-predicted RVEF also demonstrated a high discriminatory power of.87, comparable to that of FAC (.90), and significantly higher than that of TAPSE (.67). The fully automated DL-based tool using 2D echocardiography could accurately estimate RVEF and exhibited a diagnostic performance for RV systolic dysfunction comparable to that of human readers.

Left ventricular strain-volume loops in bicuspid aortic valve disease: new insights in cardiomechanics.

By combining temporal changes in left ventricular (LV) global longitudinal strain (GLS) with LV volume, LV strain-volume loops can assess cardiac function across the cardiac cycle. This study compared LV strain-volume loops between bicuspid aortic valve (BAV) patients and controls, and investigated the loop's prognostic value for clinical events. From a prospective cohort of congenital heart disease patients, BAV patients were selected and compared with healthy volunteers, who were matched for age and sex at group level. GLS analysis from apical views was used to construct strain-volume loops. Associations with clinical events, i.e. a composite of all-cause mortality, heart failure, arrhythmias, and aortic valve replacement, were assessed by Cox regression. A total of 113 BAV patients were included (median age 32 years, 40% female). BAV patients demonstrated lower Sslope (0.21%/mL, [Q1-Q3: 0.17-0.28] vs. 0.27%/mL [0.24-0.34], P < 0.001) and ESslope (0.19%/mL [0.12-0.25] vs. 0.29%/mL [0.21-0.43], P < 0.001) compared with controls, but also greater uncoupling during early (0.48 ± 1.29 vs. 0.05 ± 1.21, P = 0.04) and late diastole (0.66 ± 1.02 vs. -0.07 ± 1.07, P < 0.001). Median follow-up duration was 9.9 [9.3-10.4] years. Peak aortic jet velocity (HR 1.22, P = 0.03), enlarged left atrium (HR 3.16, P = 0.003), E/e' ratio (HR 1.17, P = 0.002), GLS (HR 1.16, P = 0.008), and ESslope (HR 0.66, P = 0.04) were associated with the occurrence of clinical events. Greater uncoupling and lower systolic and diastolic slopes were observed in BAV patients compared with healthy controls, suggesting presence of altered LV cardiomechanics. Moreover, lower ESslope was associated with clinical events, highlighting the strain-volume loop's potential as prognostic marker.

Comparative assessment of myocardial function between late premature newborns and term neonates using the 2D speckle tracking method.

Assessment of myocardial function through speckle tracking echocardiography (STE) can bring benefits to conventional echocardiography in premature newborns, a particular vulnerable group in terms of adaptation to extra-uterine life. Furthermore, it represents a non-invasive imagistic method which can guide therapeutic approach in the hemodynamically unstable newborn. This study aims to highlight the particularities of myocardial function in late premature newborns, by conducting a comparison with a group of healthy neonates, by using STE. Conducted over a timespan of two years, this prospective study enrolled 64 term neonates and 21 premature newborns, with gestational ages ranging between 28 and 36 weeks, who prior to discharge underwent a cardiac ultrasound, involving two-dimensional image acquisitions of the apical four-chamber view of both ventricles. Afterwards, the images were offline analyzed, by using the autostrain function. After segmental strain analysis, no significant discrepancies between the two groups in terms of interventricular values were found. However, left ventricle and right ventricle strain measurements differed significantly (p < 0.01), for each of the analyzed segments (basal, medial or apical). Moreover, a linear increase in interventricular (IV) basal strain with corrected gestational age progression was noted (p = 0.04). Peak global longitudinal strain (pGLS) and EF were similar between the two study groups. Premature newborns presented significantly more negative mean values of right ventricular free wall longitudinal strain (RVFWSL), (-24.19 ± 4.95 vs. -18.05 ± 5.88, p < 0.01) and of right ventricle global four chamber longitudinal strain (RV4CSL), (-19.71 ± 3.62 vs. -15.46 ± 5.59, p < 0.01), when compared to term neonates. The 2D STE is a reliable method for cardiac assessment of late preterm newborns. The evaluation of two-dimensional global longitudinal LV and RV strains might represent a useful tool in clinical practice. A better response of the right ventricle to the longitudinal deformation within premature neonates was noted. Thus, this study facilitates the identification of accurate reference values for this particular population segment, which will enable the evaluation of ventricular function in premature newborns with concurring disorders. Future longitudinal studies, assessing the fetal heart, could provide more insight into the development of myocardial function.

Effects of tricuspid transcatheter edge-to-edge repair on tricuspid annulus diameter - Data from the TriValve registry

AimsT-TEER is an effective therapy for the treatment of tricuspid regurgitation (TR). However, the effects of leaflets clipping on tricuspid valve annulus (TA) have not been investigated in detail.The aim of this study is to investigate the effects of tricuspid transcatheter edge-to-edge repair (T-TEER) on TA diameter. Methods and resultsThe TriValve registry (Transcatheter Tricuspid Valve Therapies, NCT03416166) collected 556 patients from 22 European and North American centres undergoing transcatheter tricuspid valve interventions from 2016 to 2022. Patients undergoing T-TEER with available pre- and post-procedural data on TA diameter measured in the apical 4-chamber view on transthoracic echocardiography were selected for this study. Primary end-point was the reduction of TA diameter after T-TEER.A total of 186 patients were included in the study. In 115 patients (62%) TA diameter was reduced by at least 1 mm as compared to baseline. A significant reduction of TA dimension was observed following T-TEER (mean 2.3 mm [from pre-procedural diameter 46.7 mm to post-procedural diameter 44.4 mm], p < 0.001). In particular, the greatest reduction was observed in those with T-TEER in antero-septal commissure (mean 2.7 mm [from 47.1 mm to 44.4 mm], p < 0.001) as compared to those combining both antero-septal and postero-septal commissures (mean 1.4, from 46.0 mm to 44.6 mm, P = 0.06). A significant reduction of TA dimension was recorded in patients with 1 or 2 clips implanted but not in those patients with ≥3 clips implanted. ConclusionsIn almost two third of patients T-TEER reduces TA diameter in addition to leaflet approximation. Condensed abstractThe effects of tricuspid transcatheter edge-to-edge repair (T-TEER) on tricuspid valve annulus (TA) have not been studied in details. This study investigates TA diameter as measured in apical 4-chamber view on transthoracic echocardiography before and after T-TEER.A total of 186 patients from the TriValve registry were included in the study. The study results show that 62% of patients have a TA reduction after T-TEER, especially in those receiving 1 or 2 clips in the antero-septal commissure. These suggest that T-TEER reduces tricuspid regurgitation not only by approximation of leaflets, but also by TA diameter reduction.

Atrial Septal Defect Detection in Children Based on Ultrasound Video Using Multiple Instances Learning.

Thoracic echocardiography (TTE) can provide sufficient cardiac structure information, evaluate hemodynamics and cardiac function, and is an effective method for atrial septal defect (ASD) examination. This paper aims to study a deep learning method based on cardiac ultrasound video to assist in ASD diagnosis. We chose four standard views in pediatric cardiac ultrasound to identify atrial septal defects; the four standard views were as follows: subcostal sagittal view of the atrium septum (subSAS), apical four-chamber view (A4C), the low parasternal four-chamber view (LPS4C), and parasternal short-axis view of large artery (PSAX). We enlist data from 300 children patients as part of a double-blind experiment for five-fold cross-validation to verify the performance of our model. In addition, data from 30 children patients (15 positives and 15 negatives) are collected for clinician testing and compared to our model test results (these 30 samples do not participate in model training). In our model, we present a block random selection, maximal agreement decision, and frame sampling strategy for training and testing respectively, resNet18 and r3D networks are used to extract the frame features and aggregate them to build a rich video-level representation. We validate our model using our private dataset by five cross-validation. For ASD detection, we achieve AUC, accuracy, sensitivity, specificity, and F1 score. The proposed model is a multiple instances learning-based deep learning model for video atrial septal defect detection which effectively improves ASD detection accuracy when compared to the performances of previous networks and clinical doctors.

Apical two-chamber heart view of TTE showing noncompaction of the left ventricular apical myocardium.

Apical two-chamber heart view of TTE showing noncompaction of the left ventricular apical myocardium.

Assessing fluid responsiveness with ultrasound in the neonatal intensive care setting: the mini-fluid challenge.

The mini-fluid challenge (MFC) can guide individualised fluid therapy and prevent fluid overload and associated morbidity in adult intensive care patients. This ultrasound test is based on the Frank-Starling principles to assess dynamic fluid responsiveness, but limited MFC data exists for newborns.This brief report describes the feasibility of the MFC in 12 preterm infants with late onset sepsis and 5 newborns with other pathophysiology. Apical views were used to determine the changes in left ventricular stroke volume before and after a 3ml/kg fluid bolus was given over 5min. Four out of the 17 infants were fluid responsive, defined as a post-bolus increase in stroke volume of 15% or more. Conclusion: The MFC was feasible and followed the physiological principles of stroke volume and extravascular lung water changes and 24% were fluid responsive. The MFC could enable future studies to examine whether adding fluid responsiveness to guide fluid therapy in newborns can reduce the risk of fluid overload. What is Known: • Fluid overload is associated with morbidity and mortality. • The mini-fluid challenge (MFC) provides a personalised approach to fluid therapy. What is New: • The MFC is feasible in newborns. • The MFC followed the physiological principles of stroke volume and extravascular lung water changes.

Mitral leaflet separation index correlation with mitral stenosis severity, a reliable easy 2-d echocardiography technique.

To evaluate accuracy of mitral leaflet separation index for the determination of mitral stenosis severity in patients with rheumatic mitral stenosis. The prospective, cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from March 2021 to February 2022, and comprised patients with rheumatic mitral stenosis detected on echocardiography. The best end-diastole parasternal long axis and apical four-chamber views were acquired and Mitral leaflet separation was measured as the distance between the inner edges of the tip of mitral leaflets. Pearson correlation coefficient was computed for mitral leaflet separation index and mitral valve area. Receiver operating characteristic curve was used to determine the cut-off value of the mitral leaflet separation indexto categorise mitral stenosis. Data was analysed using SPSS 19. Of the 277 patients, 205(74%) were females and 72(26%) were males. The overall mean age was 39.93±11.22 years. The mean mitral leaflet separation index value was 7.65±2.23. The correlation was significant and strong between mitral leaflet separation index and mitral valve area on planimetry (p<0.001), and was significant and moderate when measured by pressure half-time (p< 0.001). Mitral leaflet separation index cut-off value <8.625mm and <8.25mmcould predict severe mitral stenosis with 84% and 86.3% sensitivity and 84.6% and 78.3% specificity on planimetry and pressure half-time, respectively. The mitral leaflet separation index was found to be an independent, reliable and simple measure for assessing mitral stenosis severity.

Kudoa tanakai n. sp. (Myxozoa: Myxosporea: Multivalvulida), a new kudoid species with spheroid myxospores from the scalpel sawtail (Actinopterygii: Prionurus scalparum) from western Japan.

We describe a new kudoid species, Kudoa tanakai n. sp., in the scalpel sawfish, Prionurus scalprum (Actinopterygii: Acanthuriformes: Acanthuridae), from the natural water around western Japan. The plasmodia were filamentous, localized in pseudocysts in the myofibers of the trunk muscles. The occurrence of plasmodia in the trunk muscle showed no site preference. Its myxospores were spheroid, measuring 6.6-7.6 (7.0) µm by 5.8-6.9 (6.3) µm in apical view (width) and 5.7-6.6 (6.2) in length (n = 30), with four shell valves and a corresponding number of spheroid polar capsules. Shell valves lacked apical protrusions, but scanning electron microscopy revealed that one of the four shell valves had two semi-lunar flaps at its apical terminus. Nucleotide sequencing of the small and large subunit ribosomal RNA genes of the present isolate showed phylogenetic affinities to kudoid species characterized by spheroid myxospores, such as K. musculoliquefaciens, K. hemiscylli, and K. carcharhini, but was molecularly and morphometrically distinct from these and other kudoid species. For direct comparison, Kudoa hemiscylli was collected from the Pacific spadenose shark, Scoliodon macrorhynchos (Elasmobranchii: Carcharhiniformes: Carcharhinidae), in the South China Sea off Guangdong Province, China, and the myxospore surface of the species was observed using scanning electron microscopy. Our study describes the new host and distribution record of this kudoid species originally described from a variety of elasmobranchs in the Australian Coral Sea.

Echocardiographic predictors of positive left ventricular remodeling in patients with a history of active myocarditis.

Myocarditis may be difficult to diagnose because of the variety of its clinical manifestations, and the clinical course of the disease can be unpredictable. Nevertheless, some patients may exhibit partial or full contractile recovery following myocarditis. Standard and speckle-tracking echocardiography may serve as tools to follow this recovery. We aimed to evaluate predictors of positive left ventricular (LV) remodeling after active myocarditis (AM). A database of a high‑volume, tertiary cardiology center was searched for patients with AM hospitalized between 2016 and 2019. They were included in the analysis based on clinical manifestations and presence of at least 1 of the following diagnostic criteria: positive findings on electrocardiography / Holter monitoring, echocardiography, elevated troponin T/I levels, functional or structural abnormalities on cardiac imaging, or tissue characterization by cardiac magnetic resonance. LV global longitudinal strain and mechanical dispersion (MD; defined as SD of the time to peak longitudinal strain derived from all LV segments in 3 apical views) were determined. Echocardiographic response (positive LV remodeling measured by transthoracic echocardiography) was defined as end‑systolic volume (ESV) reduction by 15% or greater or end-diastolic volume (EDV) reduction by 15% or greater from the baseline values. A total of 61 consecutive patients were recruited. The median follow‑up was 1.4 years (range, 0.3-4). The mortality rate was 1.6%. Echocardiographic response was noted in 24 patients (39.4%). A multivariable Cox regression model including significant baseline differences as covariates showed that QRS duration (hazard ratio [HR], 1.31; 95% CI, 1.17-1.57; P = 0.049), MD (HR, 1.03; 95% CI, 1.01-1.07; P = 0.04), and mineralocorticoid receptor antagonist [MRA] use (HR, 8.60; 95% CI, 1.50-46.49; P = 0.01) were independently associated with positive LV remodeling with ESV reduction. MD (HR, 1.04; 95% CI, 1.02-1.06; P = 0.04) was also independently associated with positive LV remodeling with EDV reduction. Mechanical dispersion, QRS duration, and MRA use are independent predictors of positive LV remodeling in individuals with a history of AM.

Radiographic and echocardiographic evaluation in rescued Korean raccoon dogs (Nyctereutes procyonoides koreensis).

Nyctereutes procyonoides koreensis (Korean raccoon dog), a member of the Canidae family, is anatomically similar to dogs. Previous studies have used vertebral heart scale measurements to measure the cardiac size of Korean raccoon dogs on thoracic radiographs; however, the use of additional cardiac size indices, such as vertebral left arial score, intercostal space, cardiothoracic ratio, and echocardiographic indices, has not been reported. Therefore, this study aimed to establish normal reference ranges for various thoracic radiographic and echocardiographic indices in normal Korean raccoon dogs. Twenty-six Korean raccoon dogs (11 males and 15 females) were included in this study. The thoracic radiographic indices, vertebral heart scale score, and vertebral left atrial score were measured in the right lateral view. The intercostal space and cardiothoracic ratio were measured in the ventrodorsal view. The echocardiograms were evaluated in the right parasternal long and short axis view and left parasternal apical view. The mean values for the thoracic radiographic and echocardiographic indices were as follows: vertebral heart scale, 9.12 ± 0.74; vertebral left atrial score, 1.5 ± 0.31; intercostal spaces, 3.17 ± 0.34; cardiothoracic ratio, 0.69 ± 0.07; left atrial to aortic root ratio, 1.22 ± 0.14; main pulmonary artery to aorta ratio, 1.22 ± 0.14; left ventricular end-diastolic internal diameter normalized for body weight, 1.36 ± 0.19; end-diastolic volume index, 51.07 ± 19.6; end-systolic volume index, 16.54 ± 7.45; the peak velocity of early diastolic transmitral flow, 73.13 ± 15.46 cm/s; and the ratio between the transmitral flow velocities and the peak early diastolic velocity, 1.77 ± 0.47. Only percent increase in the left ventricular end-systolic internal diameter was negatively correlated with body weight. The remaining indices showed no correlations with body weight. To the best of our knowledge, this is the first case report covering both thoracic radiographic and endocardiographic indices for Korean raccoon dogs. Thus, the thoracic radiographic and echocardiographic indices established in this study may be used to evaluate the cardiac condition of Korean raccoon dogs.

Echocardiography, apical 2-chamber views showing sustained normal LV function (ejection fraction 55%) at 4-year follow up.

Echocardiography, apical 2-chamber views showing sustained normal LV function (ejection fraction 55%) at 4-year follow up.