Echocardiography Research Articles

Safety of Agitated Saline Contrast Use During Transthoracic Echocardiography in Pregnancy

Safety of Agitated Saline Contrast Use During Transthoracic Echocardiography in Pregnancy

Diabetic microvascular complications are associated with left ventricular hypertrophy in patients with type 2 diabetes mellitus.

Left ventricular hypertrophy (LVH) is an important and common pathologic change in the heart of patients with diabetes mellitus. Microvascular complications have been reported to be involved in the development and process of LVH. This study aimed to explore the association between diabetic microvascular complications and LVH in patients with type 2 diabetes mellitus (T2DM). This is a cross-sectional study. A total of 2912 patients with T2DM were enrolled, including 360 patients with LVH and 2552 patients without LVH. Demographic data, medical history and laboratory indices were collected, along with information on diabetic microvascular complications and results from cardiac ultrasonography. The study utilized multivariable logistic regression to evaluate the independent effects of microvascular complications (DR, DPN, or DKD) and the cumulative number of these complications on the presence of LVH, while adjusting for potential confounding factors. In patients with T2DM, those with LVH were older and had higher body mass index, waist circumference and hip circumference than those without LVH. Additionally, the proportion of patients with diabetic retinopathy (DR) and diabetic kidney disease (DKD) was larger among those with LVH compared to those without LVH. After adjusting for potential confounding factors, DR and DKD were associated with increased odds of LVH (odds ratio [OR]=1.351 and OR=1.404, respectively). The risk of LVH also increased progressively in patients with two or more diabetic microvascular conditions compared to those with only one. In subgroup analysis, the risk of LVH increased with the number of microvascular conditions in male patients with T2DM. Diabetic microvascular complications were significantly associated with LVH in T2DM. Moreover, the risk of LVH increased with the number of microvascular complications, particularly in males with T2DM.

Impact of impaired renal function on kinetics of high-sensitive cardiac troponin following cardiac surgery.

Impaired renal function can increase cardiac troponin levels due to reduced elimination, potentially affecting its diagnostic utility. Limited data exist on high-sensitivity cardiac troponin I (hs-cTnI) kinetics after cardiac surgery relative to renal function. This study evaluates how impaired renal function influences hs-cTnI kinetics following cardiac surgery, distinguishing between patients with and without postoperative myocardial infarction (PMI). We conducted a retrospective analysis of adult patients who underwent elective cardiac surgery at our hospital from January 2013 to May 2019. Serial hs-cTnI measurements were taken from baseline up to 48h post-surgery. Renal function was assessed using the MDRD formula, defining impaired renal function as a GFR < 60ml/min. Acute kidney injury (AKI) was based on postoperative creatinine levels, and PMI was defined by ARC-2 criteria. Predictors of long-term all-cause mortality were analyzed using Cox regression. Out of 14,355 patients (51.4% CABG, 39.4% valvular procedures, 9.2% thoracic aortic procedures), 139 (1.0%) had PMI. Hs-cTnI levels were higher in patients with impaired renal function across the cohort and in those without PMI. However, in patients with PMI, hs-cTnI levels did not vary significantly with renal function. Elevated hs-cTnI ≥ 213 times the upper limit of normal was a significant predictor of long-term mortality regardless of renal function (hazard ratio: 1.28, 95% CI: 1.17-1.40, p < 0.001), but early postoperative hs-cTnI measures held poor discriminatory yield to predict PMI with an AUC of 0.55 (95% confidence intervals: 0.54-0.56). Renal function and acute kidney injury affect hs-cTnI kinetics post-surgery only in patients without PMI. Elevated hs-cTnI remains a strong predictor of long-term mortality, independent of renal function, but early postoperative detection of PMI requires additional metrics, including ECG, transthoracic echocardiography (TTE), and signs of hemodynamic instability.

Pulmonary Valve Fibroelastoma, Still a Very Rare Cardiac Tumor: Case Report and Literature Review

Background and Clinical Significance: Primary cardiac tumors are among the rarest types of tumor, and until the mid-20th century, they were diagnosed only post-mortem or during other surgical interventions. With the rapid evolution of cardiovascular imaging and the widespread use of echocardiography, the incidence of cardiac fibroelastoma has increased, though it remains one of the rarest primary cardiac tumors. Papillary fibroelastoma is a benign primary cardiac tumor that develops from endocardial tissue, is usually solitary, and can have multiple locations, with the pulmonary valve being one of the rarest sites. The symptoms and complications depend on the tumor’s location, ranging from asymptomatic patients to cerebral ischemic embolism or pulmonary embolism. We analyzed the electronic databases PubMed, Web of Science, and Cochrane and conducted a systematic review of pulmonary valve papillary fibroelastoma (PVPF). Additionally, we included a case from the Adult and Pediatric Cardiovascular Surgery Clinic in Targu Mures. Case Presentation: We present the case of a 58-year-old patient who complained of exertional dyspnea. A transthoracic echocardiography (TTE) revealed a tumor mass attached to the pulmonary valve and coronary angiography identified severe coronary lesions. Following discussions within the Heart Team, surgical myocardial revascularization and tumor excision were decided upon due to the thromboembolic risk. Histopathological examination confirmed the diagnosis of papillary fibroelastoma. The postoperative course was uneventful, with an improvement in dyspnea. The mean age of the patients was 60 years, with half being men (n = 26, 50%). Regarding symptoms, 34% (n = 18) of cases were incidentally identified, while over 30% (n = 17) presented with dyspnea. Pulmonary embolism (PE) was reported in only two patients, and the most common associated comorbidities included high blood pressure (HBP) in 33% (n = 16) and dyslipidemia in 18%. Tumor size ranged from 0.7 cm to 3 cm with the initial benign cardiac tumor; its occurrence in the pulmonary valve remains exceedingly rare. Due to its frequent overlap with other cardiac pathologies, the clinical presentation is often a nonspecific diagnosis or suspicion of a tumor predominantly established via transthoracic echocardiography in 62% of patients. From a surgical perspective, 63% (n = 33) underwent tumor resection with valve sparing, 25% (n = 12) required pulmonary valve repair, and three patients necessitated pulmonary valve replacement. Conclusions: Although the incidence of papillary fibroelastoma is increasing, making it the most common, there is a need to highlight the indispensable role of echocardiography in diagnosis. Although papillary fibroelastoma is benign, surgical intervention is recommended, particularly in symptomatic patients, or if the tumor exceeds 1 cm in size, exhibits increased mobility, or is present alongside other cardiac surgical procedures.

Ability of dynamic chest radiography to identify left ventricular systolic dysfunction in heart failure.

Dynamic chest radiography (DCR) can estimate haemodynamic parameters in heart failure (HF). However, no studies have evaluated its ability to determine cardiac systolic function in HF. This experimental study investigates the correlation between left ventricular (LV) ejection fraction (LVEF) and DCR image parameters in HF. Ninety-one patients with acute HF (median age, 58 years; males, 75%) (cardiologist diagnosis using the Framingham criteria) underwent DCR and transthoracic echocardiography after treatment for the uncompensated phase of HF. The LV apex pixel value (PV) change was measured by DCR. Correlations between the PV change and LVEF, as well as sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of DCR, were evaluated. LVEF and LV apex PV change were correlated in all patients (R = 0.428, P < 0.001) and in patients with LVEF < 50% (n = 38; R = 0.355, P = 0.029), < 40% (n = 31; R = 0.343, P = 0.059), and < 30% (n = 23; R = 0.321, P = 0.135). There was no significant correlation for patients with LVEF ≥ 50% (n = 53; R = - 0.004, P = 0.980). The LV apex PV change rate cutoff values for identifying LVEF < 50%, < 40%, and < 30% were 9.3% (AUC: 0.761, sensitivity: 0.698, specificity: 0.789, P < 0.001), 5.5% (AUC: 0.765, sensitivity: 0.883, specificity: 0.645, P < 0.001), and 5.5% (AUC: 0.767, sensitivity: 0.838, specificity: 0.696, P < 0.001), respectively. DCR may be useful to identify LV systolic dysfunction based on LVEF in acute HF.

The Role of Circulating Biomarkers in Patients with Coronary Microvascular Disease

Coronary microvascular disease (CMD) comprises a spectrum of conditions characterized by the functional and structural abnormalities of coronary microcirculation, affecting vessels typically smaller than 500 μm. Despite its clinical significance as a contributor to myocardial ischemia, CMD frequently remains underdiagnosed due to the limitations of current diagnostic approaches. Invasive testing, including coronary reactivity assessment, is considered the gold standard, but it is resource-intensive and not always accessible. Non-invasive methods, such as positron emission tomography (PET) and transthoracic Doppler echocardiography (TTDE), offer alternatives but are limited by varying accuracy and accessibility. Amid these diagnostic challenges, there is increasing interest in circulating biomarkers as adjuncts in CMD evaluation. Biomarkers associated with endothelial dysfunction, inflammation, and oxidative stress, detectable through routine blood tests, may assist in CMD diagnosis, risk stratification, and therapeutic monitoring. These biomarkers can offer insights into CMD pathogenesis and enable early, non-invasive screening to identify patients who may benefit from more invasive investigations. This narrative review examines studies assessing biomarkers in CMD patients with diagnoses confirmed through invasive techniques. Our objective is to focus on circulating biomarkers linked to the invasive evaluation of coronary microcirculation, aiming to advance the understanding of the underlying mechanisms of this prevalent condition and enhance diagnostic accuracy and the clinical management of affected patients.

Impact of measurement location on direct mitral regurgitation quantification using 4D flow CMR.

Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) shows promise for quantifying mitral regurgitation (MR) by allowing for direct regurgitant volume (RVol) measurement using a plane precisely placed at the MR jet. However, the ideal location of a measurement plane remains unclear. This study aims to systematically examine how varying measurement locations affect RVol quantification and determine the optimal location using the momentum conservation principle of a free jet. Patients diagnosed with MR by transthoracic echocardiography (TTE) and scheduled for CMR were prospectively recruited. Regurgitant jet flow volume (RVoljet) and regurgitant jet flow momentum (RMomjet) were quantified using 4D flow CMR at 7 locations along the jet axis, x. The reference plane (mid-plane, x=0mm) was positioned at the peak velocity of the jet at each cardiac phase, and 3 additional planes were positioned on either side of the jet, each 2.5mm apart. RVoljet was compared to RVolTTE, measured by the proximal isovelocity surface area method and RVolindirect, measured by subtracting aortic forward flow volume from the left ventricle stroke volume derived from 2D phase-contrast at the aortic valve and a stack of short-axis cine CMR techniques. RVoljet and RMomjet were quantified in 45 patients (age 63±13, male 26). In patients with RVoljet at x=0mm ≥ 10ml (n=25), RVoljet consistently increased as the plane moved downstream. RVoljet measured furthest upstream (x=-7.5mm) was significantly lower (39±11%, p<0.001) and RVoljet measured furthest downstream (x=7.5mm) was significantly higher (16±19%, p<0.001) than RVoljet at x=0mm. RMomjet similarly increased from x=-7.5 to 0mm (57±12%, p<0.001) but stabilized from x=0 to 7.5mm (-2±17%). From x=-7.5 to 7.5mm, RVoljet was in consistent moderate agreement with RVolindirect (n=41, bias=-2±24 to 8±32ml, ICC=0.55 to 0.63, p<0.001). The location of a measurement plane significantly influences RVol quantification using the direct 4D flow CMR approach. Based on the converging profile of RMomjet, we propose the peak velocity of the jet as the optimal position.

Unravelling ATTR Cardiac Amyloidosis in Iceland: A Nationwide Epidemiological Study

Introduction: Cardiac amyloidosis (CA) arises from the deposition of misfolded amyloid proteins in the heart's extracellular matrix, leading to significant cardiac disease. Recent data suggest that CA is under recognised and advances in treatment have increased focus on this condition with the intention of implementing treatment earlier to improve prognosis. There is limited knowledge regarding the prevalence of Transthyretin-CA (ATTR-CA) on a national level, particularly in Iceland. Therefore, this study represents the first nationwide effort to evaluate the baseline characteristics, diagnostics, and treatment of ATTR-CA in Iceland. Methods: A retrospective study of all patients diagnosed with ATTR-CA in Iceland from 6 May 2013 to 11 March 2024 were identified in the Icelandic Cardiac Amyloid Registry (ICE-CAR) created in 2023 by heart failure (HF) specialists at Landspitali University Hospital in Reykjavik, Iceland. Diagnosis was based on different combinations of transthoracic echocardiography (TTE), an elevated Perugini score on bone scintigraphy and heart biopsies, as well measurements of free light chains, M-component measurements in blood and urine. Patients were grouped according to the National Amyloidosis Centre (NAC) prognostic staging system for ATTR-CA. Results: In total, 65 patients with ATTR-CA were identified (males n=60, females n=5, median age 81.4 years [IQR 75.5-85.5 years]), all wild-type and no mutant variant. Diagnosis was made with myocardial biopsy in 7 cases. Upon diagnosis, 83% of the patients had an interventricular septum thickness of ≥15mm and 92% showed a posterior wall thickness of ≥12mm. Approximately 57% of patients belonged to New York Heart Association (NYHA) functional class I-II. The HF phenotypes according to left ventricular ejection fraction (LVEF) were distributed as follows: reduced (HFrEF) n=24 (37%), mildly reduced (HFmrEF) n=9 (14%), preserved (HFpEF) n=29 (44.5%), and unknown LVEF n=3 (4.5%). A total of 54 patients had reported NAC stage: Stage I 23 (35.4%), Stage II 20 (30.8%), Stage III 11 (16.9%). Around 32% received disease modifying treatment. Conclusion Despite the low NYHA class observed in the study population, our findings in Iceland's nationwide assessment of ATTR-CA indicate more advanced age and lower LVEF at diagnosis compared to other studies. This highlights the critical need for early detection and appropriate therapeutic interventions in managing ATTR-CA.

Two Types of Double Chambered Left Ventricle: a case series

Abstract Background Double Chambered Left Ventricle (DCLV) is a rare anatomical variant of the left ventricular structure characterized by the division of the left ventricle into two distinct chambers due to abnormal muscle bundles or septa. This anomaly typically results in primary and secondary chambers within the left ventricle. Due to the lack of conspicuous clinical symptoms, DCLV is often overlooked. Case Summary The first patient was a 69-year-old male experiencing intermittent chest tightness for several weeks. Transthoracic echocardiography indicated the presence of Type A DCLV, which was subsequently confirmed by 3D echocardiography and cardiac magnetic resonance imaging. A few months later, during a routine transthoracic echocardiographic examination of a 48-year-old male, we unexpectedly discovered Type B DCLV. His unique cardiac structure was clearly demonstrated through 3D echocardiography. Discussion DCLV is a rare structural heart malformation often overlooked due to atypical symptoms. This paper presents two cases of DCLV within a six-month period, illustrating two distinct classifications. Comprehensive understanding of the imaging manifestations of DCLV is imperative for accurate clinical diagnosis.

Echocardiographic evaluation of inferior vena cava diameters and collapsibility index in healthy children.

Introduction. Echocardiographic measurement of inferior vena cava diameters and collapsibility index (IVCCI) can estimate right heart chamber function and intravascular volume status. Few reports of reference values for diameters and IVCCI in the pediatric population exist. This exploratory study aimed to understand the behavior of diameters and IVCCI as a function of body surface area (BSA) in healthy children to establish possible reference values in the future. Population and methods. Ninety-nine Mexican children aged 12 to 204 months were included. Anthropometry and transthoracic M-mode echocardiography were performed to assess the maximum expiratory diameter (MAXDE) and the minimum inspiratory diameter (MINDI). IVCCI was calculated with the formula (MAXDE - MINDI) / MAXDE × 100. Results. A linear regression model was performed to calculate the predicted values (mean ± 2 standard deviations of MAXDE and MINDI expressed per BSA). The predicted value of the IVCCI for each representative BSA value was calculated from the MAXDE and MINDI values predicted by the model. Conclusions. Variations were found in the values of diameters and IVCCI concerning studies performed in other pediatric groups. This indicates the importance of having specific reference values for each population and opens the door to generating more research in healthy children and even those with cardiac disorders.

Left atrial myopathy in rheumatic mitral stenosis; three-dimensional and speckle tracking echocardiography study

Background In developing countries, rheumatic mitral valve stenosis (MS) is still a problem and its progression leads to left atrial (LA) damage. Due to the complexity of the LA geometry, currently used techniques like antero-posterior dimension (LAD) and 2D echo derived LA volume (LAV) have several limitations that are corrected by 3D derived LA volumes in addition to functional evaluation. Purpose To assess the LA functions using 2D speckle tracking echocardiography and 3D transthoracic echocardiography in patients with clinically significant MS in comparison to normal healthy subjects. Results Fifty patients and 50 healthy controls were studied. Patients’ mean age was 40.2 ± 8.8 years, the majority were female 45(81.8%). 3D indexed LA maximum (LAVmaxI) and minimum (LAVminI) volumes were significantly higher in MS than in the control group, whereas 3D LA EF was significantly lower in MS than in the control group (p 0.001). LA strain reservoir, conduit, and contraction parameters were significantly lower in the MS group than in the control group (p = 0.001). However, only 3D LAEF, 2D LASr, 2D LAScd, and 2D LASct showed a correlation with the mitral valve area with a p < 0.05, but 3D LAVmaxI and 3D LAVminI did not. Additionally, in the comparison of severe and very severe mitral stenosis subgroups, 3D LAVmaxI and 3D LAVminI did not show any statistically significant differences between the two groups, although 3D LAEF, 2D LASr, 2D LAScd, and 3D LASct showed significant difference between the two groups (p < 0.05). Conclusions Left atrial functional and structural remodelling has been highlighted in patients with significant rheumatic MS. However, left atrial functional assessment by 3D echocardiography and 2D speckle tracking echocardiography correlate better with mitral valve area than conventional LA size measurements. Whether the functional assessment of the LA has an additive predictive value with regards to patient outcome needs to be interrogated.

Accuracy of transthoracic echocardiography in diagnosis of cardiac myxoma: single center experience.

The differential diagnosis of cardiac myxomas (CM), the most common benign primary cardiac tumors, is broad and a thorough diagnostic workup is required to establish accurate diagnosis prior to surgical resection. Transthoracic echocardiography (TTE) is usually the first imaging modality used for diagnosis of suspected CM. In a single tertiary centre study, we sought to determine the accuracy, sensitivity, and specificity of TTE in the diagnosis of CM and to determine echocardiographic characteristics indicative of CM. We retrospectively analyzed clinical, echocardiographic, and pathohistological findings of 73 patients consecutively admitted for suspected CM. After diagnostic workup, 53 (73%) patients were treated surgically at our institution. Based on preoperative TTE, patients were divided into a CM group (n=45, 85%) and non-myxoma (NM) group. Of the 53 pathohistological specimens obtained during surgery, 39 (73%) were CM. The sensitivity and specificity of preoperative echocardiography were 97% and 50%, respectively. The overall accuracy was 85%. All NM tumors were found in an atypical location and 72% of CM were found in a typical position in the left atrium (p < 0.001). Tumors in NM group were significantly smaller than CM (24.3 ± 13.2 mm vs. 37.9 ± 18.3 mm, p = 0.017). Our study confirms very good accuracy of TTE in the diagnosis of CM. The most important echocardiographic characteristics to differentiate between CM and tumors of different etiology are tumor location and size. Smaller tumors presenting at an atypical location are less likely to be diagnosed as CM, and these require additional imaging modalities for accurate diagnosis.

Echocardiographic Assessment of Biventricular Mechanics in Patients with Mild-to-Moderate Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis

Background: Over the last few years, a few imaging studies have performed conventional transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography (STE) for the assessment of biventricular mechanics in patients with non-advanced idiopathic pulmonary fibrosis (IPF). This systematic review and meta-analysis aimed at evaluating the overall effect of mild-to-moderate IPF on the main indices of biventricular systolic function assessed by TTE and STE. Methods: All imaging studies assessing right ventricular (RV)-global longitudinal strain (GLS), left ventricular (LV)-GLS, tricuspid annular plane systolic excursion (TAPSE), and left ventricular ejection fraction (LVEF) in IPF patients vs. healthy controls, selected from PubMed, Scopus, and EMBASE databases, were included. Continuous data (RV-GLS, LV-GLS, TAPSE, and LVEF) were pooled as standardized mean differences (SMDs) comparing the IPF group with healthy controls. The SMD of RV-GLS was calculated using the random-effect model, whereas the SMDs of LV-GLS, TAPSE, and LVEF were calculated using the fixed-effect model. Results: The full texts of 6 studies with 255 IPF patients and 195 healthy controls were analyzed. Despite preserved TAPSE and LVEF, both RV-GLS and LV-GLS were significantly, although modestly, reduced in the IPF patients vs. the controls. The SMD was large (−1.01, 95% CI −1.47, −0.54, p &lt; 0.001) for RV-GLS, medium (−0.62, 95% CI −0.82, −0.42, p &lt; 0.001) for LV-GLS, small (−0.42, 95% CI −0.61, −0.23, p &lt; 0.001) for TAPSE, and small and not statistically significant (−0.20, 95% CI −0.42, 0.03, p = 0.09) for LVEF assessment. Between-study heterogeneity was high for the studies assessing RV-GLS (I2 = 80.5%), low-to-moderate for those evaluating LV-GLS (I2 = 41.7%), and low for those measuring TAPSE (I2 = 16.4%) and LVEF (I2 = 7.63%). The Egger’s test yielded a p-value of 0.60, 0.11, 0.31, and 0.68 for the RV-GLS, LV-GLS, TAPSE, and LVEF assessment, respectively, indicating no publication bias. On meta-regression analysis, none of the moderators was significantly associated with effect modification for RV-GLS (all p &gt; 0.05). The sensitivity analysis supported the robustness of the results. Conclusions: RV-GLS impairment is an early marker of subclinical myocardial dysfunction in mild-to-moderate IPF. STE should be considered for implementation in clinical practice for early detection of RV dysfunction in IPF patients without advanced lung disease.

Artificial intelligence-enhanced comprehensive assessment of the aortic valve stenosis continuum in echocardiography.

Transthoracic echocardiography (TTE) is the primary modality for diagnosing aortic stenosis (AS), yet it requires skilled operators and can be resource-intensive. We developed and validated an artificial intelligence (AI)-based system for evaluating AS that is effective in both resource-limited and advanced settings. We created a dual-pathway AI system for AS evaluation using a nationwide echocardiographic dataset (developmental dataset, n=8427): 1) a deep learning (DL)-based AS continuum assessment algorithm using limited 2D TTE videos, and 2) automating conventional AS evaluation. We performed internal (internal test dataset [ITDS], n=841) and external validation (distinct hospital dataset [DHDS], n=1696; temporally distinct dataset [TDDS], n=772) for diagnostic value across various stages of AS and prognostic value for composite endpoints (cardiovascular death, heart failure, and aortic valve replacement). The DL index for the AS continuum (DLi-ASc, range 0-100) increased with worsening AS severity and demonstrated excellent discrimination for any AS (AUC 0.91-0.99), significant AS (0.95-0.98), and severe AS (0.97-0.99). DLi-ASc was independent predictor for composite endpoint (adjusted hazard ratios 2.19, 1.64, and 1.61 per 10-point increase in ITDS, DHDS, and TDDS, respectively). Automatic measurement of conventional AS parameters demonstrated excellent correlation with manual measurement, resulting in high accuracy for ASstaging (98.2% for ITDS, 82.1% for DHDS, and 96.8% for TDDS) and comparable prognostic value to manually-derived parameters. The AI-based system provides accurate and prognostically valuable AS assessment, suitable for various clinical settings. Further validation studies are planned to confirm its effectiveness across diverse environments. This work was supported by a grant from the Institute of Information & Communications Technology Planning & Evaluation (IITP) funded by the Korea government (Ministry of Science and ICT; MSIT, Republic of Korea) (No. 2022000972, Development of a Flexible Mobile Healthcare Software Platform Using 5G MEC); and the Medical AI Clinic Program through the National IT Industry Promotion Agency (NIPA) funded by the MSIT, Republic of Korea (Grant No.: H0904-24-1002).

Effects of patent foramen ovale in migraine: a metabolomics-based study.

Patent foramen ovale (PFO), a cardiac anatomical anomaly inducing abnormal haemodynamics, leads to a paradoxical bypass of the pulmonary circulation. PFO closure might alleviate migraines; however, clinical evidence and basic experiments for the relationship are lacking. To explore the effect of PFO on migraine, 371 migraineurs finishing blood tests and contrast transthoracic echocardiography for the detection of PFO were prospectively included. Multivariate regression analysis revealed that PFO was independently associated with aura, and lower cystatin-C (cys-C) and calcium levels. Among them, patients with PFO who underwent percutaneous PFO closure were continuously followed up 1year after the operation. The intensity of migraine was significantly relieved and the levels of cys-C and calcium increased after PFO closure. Untargeted and targeted metabolomics of plasma from migraineurs before and after PFO closure revealed that 5-HT and glutathione (GSH) metabolites were differentially expressed after PFO closure. The differential metabolites were then validated in the plasma and brain tissues of PFO mouse models by LC-MS/MS analysis. Desorption electrospray ionization mass imaging demonstrated that these metabolic alterations occurred mainly in the posterior cerebral cortex. Collectively, aura, cys-C and calcium could be biomarkers of migraineurs with PFO. PFO might have an impact on the posterior head associated with the regulation of 5-HT and GSH. PFO closure might relieve migraine by improving 5-HT clearance metabolism and ameliorating redox reactions. Our results may provide evidence for an indication of PFO closure in migraine and support the related potential mechanism. KEY POINTS: Aura, and levels of cystatin-C and calcium are biomarkers of migraineurs with a patent foramen ovale (PFO). The clearance of pulmonary metabolism of 5-HT and deoxygenated blood might be the reason for the improvement of migraine symptoms in patients with PFO. The posterior region of the brain is the main area responsible for PFO-induced migraine.

Echocardiography parameters and cardiac geometry in pregnancy by race and ethnicity.

The objective of this study was to assess transthoracic echocardiography (TTE) parameters in pregnancy by race and ethnicity. We performed a retrospective cohort study of pregnant individuals without cardiovascular disease who underwent a perinatal TTE between October 2017 and May 2022. Demographics and echocardiographic parameters were compared by race/ethnicity. Multivariate regression analysis was performed for TTE parameters after adjusting for age and hypertension. During the study period, 369 individuals had TTEs with a mean age of 31.8 ± 6.0 years old. Subjects were 55.3% White, 24.7% Hispanic, 14.1% Black, and 6.0% Asian. TTE parameters of left ventricular (LV) ejection fraction and LV mass index differed by race/ethnicity, though no difference was seen in cardiac geometry. The differences in TTE parameters may not be clinically significant as most values fall within normal clinical ranges. Further prospective studies are needed to better evaluate cardiac outcomes by differences in echocardiographic parameters in pregnancy.

Sacubitril/valsartan on right ventricular-pulmonary artery coupling and albumin-bilirubin score in heart failure in Chinese patients with reduced ejection fraction

ObjectiveImpaired right ventricular (RV)-pulmonary arterial (PA) coupling, calculated by measuring the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), can be used as an early indicator of right ventricular dysfunction (RVD) in patients with heart failure with a reduced ejection fraction (HFrEF). Patients suffering from HFrEF experience improvements in left ventricular (LV) function through the administration of sacubitril/valsartan therapy. In addition, the albumin-bilirubin (ALBI) score was associated with the fluid overload status and adverse clinical outcomes in patients with heart failure. This study aimed to assess whether angiotensin receptor-neprilysin inhibitor (ARNI) affects the TAPSE /PASP in patients with HFrEF, and whether there is a correlation between changes in the ALBI score and ARNI treatment.MethodsA retrospective observational study was conducted on 305 patients with HFrEF and RVD who were hospitalized between June 2020 and December 2021. One year after treatment, laboratory test results, ALBI score, transthoracic echocardiography (TTE), New York Heart Association classification, Minnesota Living with Heart Failure Questionnaire scores and changes in relevant variables were reevaluated.ResultsCompared to before sacubitril/valsartan treatment, the ALBI was found to be significantly reduced after one year of follow-up (-2.42 ± 0.37 vs. -2.51 ± 0.32, p < 0.001). Additionally, A significant improvement was demonstrated in the following echocardiography parameters assessing RV function after 1 year of treatment with sacubitril/valsartan: TAPSE (15 ± 1 vs. 18 ± 2 mm, p < 0.001), PASP (45 ± 8 vs. 40 ± 9 mmHg, p < 0.001), pulmonary artery diastolic pressure (PADP) (22 ± 4 vs. 19 ± 4 mmHg, p < 0.001), RV-PA coupling (0.35 ± 0.08 vs. 0.48 ± 0.12, p < 0.001), and RV s’(8.7 ± 2.2 vs. 9.5 ± 2.6 cm/s, p < 0.001). Multivariate analysis showed that the improvement of RV-PA coupling was associated with baseline PASP (r: -0.45, p < 0.001) and PADP (r: -0.45, p < 0.001).ConclusionsSacubitril/valsartan improves RV-PA conjugation in patients with RVD and HFrEF, and has a positive impact on the ALBI score by improving liver function in patients with HFrEF.

Echocardiography evaluation of iatrogenic atrial septal defect after combined procedure of catheter ablation and left atrial appendage closure for atrial fibrillation

Using transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) to investigate the occurrence and related causes of iatrogenic atrial septal defect (iASD) after catheter ablation combined with left atrial appendage closure (LAAC) for atrial fibrillation (AF) and its impact on the right heart system. We retrospectively analyzed 330 patients that underwent combined procedure of catheter ablation for AF and LAAC at General Hospital of Northern Theater Command from January 2018 to March 2022. These patients were divided into iASD group and non-iASD group according to whether there was persistent iASD shown on TEE at 3 months after procedure. There were 96 (29.1%) patients with iASD and 234 patients without in the TEE follow up at 3 months post-operation. Patients with iASD had larger left atrial volumes (76.5 ± 35.2 ml vs. 61.1 ± 21.9 ml, p = 0.036) as well as higher occurrence of mitral regurgitation (MR) (32.3% vs. 12.8%, p = 0.018) and tricuspid regurgitation (TR) (27.1% vs. 7.3%, p = 0.002). Procedural features showed that patients with persistent iASD had longer procedure time (92.1 ± 36.3 vs. 69.1 ± 17.8 min, p = 0.003) and larger sheath sizes (4.1 ± 1.2 mm vs. 3.3 ± 1.2 mm, p = 0.022). The preoperative and postoperative right heart parameters of patients in the persistent iASD group were compared, and there were no significant differences on right atrial/ventricular diameter, right heart systolic/diastolic function and pulmonary artery pressure (P > 0.05). The occurrence of iASD 3 months after combined atrial fibrillation ablation and LAAC was 29.1%. The size of left atrium, the pressure of left atrium, the manipulation time within left atrium, the size of sheath, and the use of ICE during operation was related to the closure of iASD.

Structural and Functional Remodeling for Elite Cyclists During Exercise; Pressure Volume Loops and Hemodynamic Forces Analysis.

The study was designed to investigate the pattern of intraventricular Hemo-Dynamic Forces (HDF) and myocardial performance during exercise in Elite Cyclists (EC). Transthoracic stress echocardiography was performed on nineteen EC and thirteen age-matched sedentary controls (SC) at three incremental exercise intensities based on Heart Rate Reserve (HRR). Left Ventricular (LV) HDF were computed from echocardiography long-axis data sets using a novel technique based on endocardial boundary tracking, both in apex-base and latero-septal directions. Pressure Volume (PV) loops were non-invasively investigated using the single-beat approach. Differences between groups were investigated using mixed model analysis. At PV loops EC showed a steeper increase in stroke work compared to SC, without acute changes in ventricular capacity (EDVI20). Contractility, measured as Ventricular Elastance (Ees), increased during exercise with no difference between groups (P=0.625). At rest, EC had significantly lower heart rates and generated lower HDF than SC. However, during exercise the pressure gradient developed by EC in systole, and therefore systolic HDF, was significantly higher than that developed by SC (P<0.009), also showing greater elastic rebound in late systole compared to SC (P<0.032). Importantly, during early diastolic filling, EC showed lower HDF deceleration than SC (P<0.043), indicating a facilitated relaxation of the left ventricle. Analysis of the HDF pattern during exercise shows the functional changes that occur in EC, characterized by increased HDF generation in systole, and facilitated relaxation in early diastole. This is the first time LV structural and functional remodeling is reported for elite cyclists during exercise.

25 years of Ross operation in adults: the inclusion technique keeps up the expectations.

In adults the Ross procedure provides an excellent alternative to prosthetic valves, but it is underutilised because of concerns about technical complexity, durability, and perceived high late reoperation rates. The inclusion technique stabilizes the aortic root, prevents dilatation, and respects the dynamic root physiology. Long-term outcomes of the Ross procedure with the inclusion cylinder technique (1992-2022) are reported. Long-term (12.2, 95% CI 11.5-12.8 years) single institution results, with more than 25 years follow up in 44 patients. Total of 516 patients aged 39 (SD±13) years underwent Ross procedure with inclusion cylinder and annular reduction. All had yearly clinical review and biannual transthoracic echo. The aetiology of valve disease comprised aortic stenosis (AS) n=233 (44.8%), aortic regurgitation (AR) n=179 (34.4%), mixed AS/AR n=108 (20.8%). The Primary endpoints were 25-year survival and freedom from reoperation, with degree of autograft regurgitation in all morphologies (AS, AR, mixed AR/AS) the secondary endpoint. Total reoperation rate was 8.3% after 25 years (n=43, AoV=28, PV=15), with early reoperation <1y in 0.6% and early postoperative death (n=1, 0.2%) following myocardial infarction. Overall, 25-year survival was 85.3%, and 25-year freedom from autograft reoperation 89.5% (AS=95.0%, AR=78.0%, Mixed AS/AR=94.3%), (p=0.01). Freedom from redo pulmonary valve replacement was 92.7%. The Ross procedure with inclusion cylinder technique provides excellent haemodynamics. Autograft inclusion in native aorta minimizes prosthetic material and respects physiological root changes, reducing shear stress on neo-aortic cusps and increasing durability. Long-term reoperation rate is low in experienced centers.