Conventional 2D Echocardiography Research Articles

Left atrial appendage morphology and function predict thromboembolic risk in patients with embolic stroke of undetermined sources

Abstract Introduction Embolic stroke of undetermined sources (ESUS) is supposed to be associated with intracardiac thrombus formation, in particular in the left atrial appendage (LAA). We aimed to investigate the impact of LAA morphology and function on thromboembolic risk condition (TRC) and LAA thrombus in ESUS patients. Methods 185 ESUS patients (mean age 68 ±13 years, 33% female) without history of AF were included. All patients underwent clinical evaluation by CHA2DS2-VASc and complete transthoracic and transesophageal echocardiography shortly after index ESUS (4 days, IQR 3-6). LAA function and LAA morphology were evaluated by conventional 2D and 3D echocardiography and speckle tracking strain. TRC was defined as combination of thrombus, sludge and spontaneous echo contrast (SEC) in LAA. Results In 185 study patients, following LAA types were found: chicken wing (LAA CW) 79 (43%), windsock 64 (34%), cactus 35 (19%), cauliflower 7 (4%) and multilobate LAA, defined as LAA with ≥ 1 lobe, in 115 (62%) of patients. TRC was found in 123 (67%) and thrombus formation in 29 (16%). LAA CW and multilobate LAA were independent predictors of TRC (OR 2.3 (CI 1.2 - 4.5), p= 0. 01 and OR 2.2 (CI 1.2 - 4.2), p= 0.02, respectively) and furthermore, LAA CW and LAA-Sr were independent predictors of LAA thrombus (OR 2.5 (CI 1.1 - 5.8), p=0.04 and OR 0.9 (CI 0.8 – 1.0), p<0.01, respectively), all adjusted for CHA2DS2-VASc-score. Conclusion LAA type CW, multilobate LAA and novel LAA strain predicted independently TRC and LAA thrombus, respectively. These results indicate that LAA morphology and function are important in assessment of thromboembolic risk in ESUS patients.Table 1.

Abstract 17362: Left Atrial Stiffness is Increased in Pediatric Hypertrophic Cardiomyopathy and May Be of Incremental Value in Predicting Major Adverse Cardiac Events in This Group

Background: Determining risk factors by echocardiography to prevent major adverse cardiac events (MACE) is crucial in pediatric patients with hypertrophic cardiomyopathy (HCM). Recent studies have shown that LA stiffness and strain may serve as surrogate markers in children, to differentiate elevated pulmonary capillary wedge pressure from normal and predict COVID-19 related myocardial injury. Hypothesis: LA stiffness may predict MACE in pediatric patients with HCM. Methods: We retrospectively enrolled 201 pediatric patients with HCM diagnosed by echocardiography. They were divided into two groups: MACE (n=61) and non-MACE (n=140) groups. LV systolic function, and LA strain were evaluated by conventional 2D and speckle tracking echocardiography. Noninvasive LA stiffness was calculated as the ratio of E/e’ to LA strain as depicted in the following equation: LA Stiffness= E/e ' ratio / LA Peak Strain (% -1 ). The primary outcome was a composite endpoint of MACE (including ICD placement, myomectomy, heart transplant or death) during follow-up. Results: The MACE group showed significantly decreased LV global longitudinal strain (GLS) compared to non-MACE group (GLS - 16.76 ± 5.05% vs. - 20.25 ± 3.40%, p < 0.001), even though LV ejection fraction showed no significant difference between the two groups. LA peak strain was significantly reduced (21.96 ± 7.24% vs. 30.80 ± 7.10%, p < 0.001), whereas, noninvasive LA stiffness was significantly increased (0.72 ± 0.48 % -1 vs. 0.34 ± 0.16 % -1 , p < 0.001) in the MACE group. Among the LV diastolic indices, LA stiffness was the superior-most index for predicting MACE (see Table 1, Figure 1) (AUC: 0.814, cut off value: 0.49% -1 ). Also, LA stiffness was independently associated with increased risk of the composite endpoint of MACE (HR: 3.26 [95% CI: 1.77 -5.99]; P < 0.001, see Table 2). Conclusion: LA stiffness is a newly described index in children, that may be of incremental value in predicting risk of MACE in pediatric HCM patients.

Baseline mechanical dyssynchrony is associated with better diastolic function in patients undergoing cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovative program under the Marie Sklodowska -Curie grant agreement No. 860745. Background Outcome after cardiac resynchronization therapy has been shown to be worse in patients with diastolic dysfunction. Aim We aim at investigating the association between baseline mechanical dyssynchrony (Dyss) and diastolic function, both assessed using conventional 2D echocardiography in heart failure patients undergoing cardiac resynchronization therapy (CRT). Methods Datasets of 219 patients were retrospectively analyzed, including full echocardiographic diastolic function assessment before CRT implantation. Using the guideline approach (Nagueh et al 2016) for estimating left atrial pressure (LAP), patients were classified as elevated LAP (eLAP = 49%), normal LAP (nLAP = 40%), and undetermined LAP (uLAP = 11%). Patients with nLAP and uLAP together were referred to as non-elevated LAP (non-eLAP = 51%). Dyss was defined as the presence of apical rocking (ApRock) and /or septal flash (SF). All baseline characteristics, comorbidities, ECG data and left atrial (LA) strain components (reservoir, conduit, and pump strains) were collected and analyzed. The amount of CRT-induced LV reverse remodeling was assessed at 12±6 months after CRT and was defined as percentage decrease of LV end-systolic volume (LVESV) compared to baseline. Patients were followed up for a mean of 4.8 years (interquartile range (IQR): 2.7–6.0) for all-cause mortality. Results Compared to patients without Dyss, patients with Dyss were significantly more of female sex (39% vs. 14%), had less diabetes mellitus (21 vs. 34%), had lower serum creatinine (1.2±0.5 vs. 1.4±0.6 mg/dl) and less prevalence of ischemic cardiomyopathy, 43% vs. 68%). They used significantly more ACEi (91% vs. 76%). ECG data showed that they had less prevalence of AF (8 vs. 22%) and had wider QRS complex (158±18 vs. 152±18 msec), P-values <0.05 for all comparisons. Baseline LV volumes and EF were not significantly different between patients with and without Dyss. Patients with Dyss show less prevalence of eLAP compared to patients without Dyss (30% vs. 60%, P <0.001, figure A). Additionally, they had better LA function on all LA strain indices (Figure B). In the multivariable analysis for predicting the association with eLAP, the presence of Dyss was independently associated with less eLAP after adjusting for most of the baseline variables (HR: 0.31, CI: 0.1–0.7, P <0.01). At follow up, patients who had both Dyss and non-eLAP before CRT showed the largest amount of LV reverse remodeling compared to other patients. Similarly, the patients with Dyss and non-eLAP showed the best survival compared to other groups (figure C). Conclusion The presence of mechanical dyssynchrony is associated with better diastolic function and lower estimated LAP before CRT. Additionally, the combination of Dyss and non-eLAP before CRT was associated with the most CRT-induced LV reverse remodeling and best long-term survival.

Incremental value of right atrial strain analysis to predict atrial fibrillation recurrence after electrical cardioversion

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is the most frequent cardiac arrhythmia, associated with elevated risks of cardiovascular events and death. The assessment of left atrial (LA) mechanics has been reported to refine AF risk prediction, however it does not completely predict AF relapse. The potential added role of right atrial (RA) function in this setting is unknown. Purpose This study sought to evaluate the added value of RA longitudinal reservoir strain (RARS), on top of LA longitudinal reservoir strain (LARS) analysis, for the prediction of AF recurrence after electrical cardioversion (ECV). Methods We retrospectively studied 132 consecutive adult patients (men 55%, 72±10 years) with persistent AF undergoing ECV in hospital setting. Exclusion criteria were: pregnancy, previous cardiac surgery, pacemaker or implantable cardioverter defibrillator, severe valvular regurgitation/stenosis, ventricular systolic dysfunction, poor apical acoustic window, unsuccessful ECV, early recurrent AF and lack of follow-up. LA and RA size and function were analyzed by conventional 2D and speckle-tracking echocardiography before ECV. The endpoint was AF recurrence. Results After a total follow-up of 12 months, 63 patients (48%) showed AF recurrence. Both LA and RA reservoir strain were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LARS 10±6 vs 13±7%, RARS 14±10 vs 20±9 %, respectively, p<0.001 for both). By receiving operating curve (ROC) analysis, the best cut-offs associated to AF recurrence after ECV were 15% for RARS [AUC 0.77 (95%CI 0.69–0.84), p<0.0001] and 10% for LARS [AUC 0.69 (95%IC 0.60–0.77), p<0.0001]. Kaplan-Meier curves showed that patients with both LARS≤10% and RARS ≤15% had a significant risk for AF recurrences (log-rank, p<0.001) (Figure 1). However, at multivariable Cox regression, RARS [HR 3.26, 95%CI (1.73–6.13), p< 0.001] was the only parameter independently associated with the AF recurrence. RARS provided incremental prognostic value over LARS, LA and RA volumes concerning the prediction of AF relapse after ECV (Figure 2). Conclusions RARS was independently associated with AF recurrence after ECV and provided an incremental prognostic value over LARS. This study highlights the importance of assessing the functional remodeling of both RA and LA in patients with persistent AF. Figure 1. Atrial fibrillation recurrence freedom according to left and right atrial reservoir longitudinal strain. Kaplan-Meier plots of patients grouped according to the threshold levels of left (left panel) and right (right panel) values of reservoir longitudinal strain identified by the Receiver Operating Curve analyses.

Ventricular Functional Analysis in Congenital Complete Heart Block Using Speckle Tracking: Left Ventricular Epicardial Compared to Right Ventricular Septal Pacing.

Chronic right ventricular (RV) apical pacing in patients with congenital complete atrioventricular block (CCAVB) is associated with left ventricle (LV) dyssynchrony and dysfunction. Hence, alternative pacing sites are advocated. The aim of this study was to compare LV function using STE in selected patients with LV epicardial pacing (LVEp) vs. RV transvenous pacing (RVSp). This was a single-center, retrospective study in patients with CCAVB who underwent permanent pacemaker implant at age ≤ 18years. Age- and gender-matched patients with a normal heart anatomy and function served as the control group. LV function was comprehensively assessed by conventional 2D Echocardiography and speckle-tracking echocardiography (STE). We included 24 patients in the pacemaker group [27.6% male, mean age of 17.1 at last follow-up, follow-up duration of 8.7years, RVSp (n = 9; 62.5%)] compared to 48 matched healthy controls. Shortening fraction (SF) and ejection fraction (EF) were normal and similar between cases and controls. However, STE detected abnormal LV function in the pacemaker group compared to controls. The former demonstrated lower/abnormal, Peak Longitudinal Strain myocardial (PLS Myo) [- 12.0 ± 3.3 vs. - 18.1 ± 1.9, p < 0.001] and Peak Longitudinal Strain endocardial (PLS endo) [- 16.1 ± 4.1 vs. 1.7 ± 1.7, p < 0.001]. STE parameters of LV function were significantly more abnormal in LVEp vs. RVSp subgroup as demonstrated by lower values for PLS Myo (- 10.1 ± 3.2 vs. - 13.1 ± 2.9, p = 0.03) and PLS Endo (- 13.8 ± 4.4 vs. - 17.5 ± 3.3, p = 0.03). STE was more sensitive in detecting subtle differences in LV function relative to standard conventional 2D echocardiography (SF and EF) in selected patients with CCAVB and a permanent pacemaker. Furthermore, STE demonstrated that transvenous RV septal pacing was associated with better LV systolic function preservation than LV epicardial pacing for comparable post-implant intervals.

Three-dimensional Echocardiography during Percutaneous Mitral Balloon Valvuloplasty

Percutaneous mitral balloon valvuloplasty (PMBV) has been frequently used as an alternative to open or closed surgical mitral commissurotomy for the treatment of selected patients with symptomatic rheumatic mitral stenosis. PMBV has been proven a safe and effective method, often performed under fluoroscopic guidance. With the advent of three-dimensional echocardiography (3DE), interventional cardiologists have been able to successfully perform complex procedures such as paravalvular leak closure, transcatheter edge-to-edge repair of the mitral valve (MV) using MitraClip, etc. With the expertise derived from these procedures, 3DE has received considerable interests in many other procedures, including PMBV. Pre-, intra-, and postprocedural assessments of the mitral valve (MV) area; commissural splitting; the presence, degree, and location of mitral regurgitation; and other procedure-related complications can be more accurately and readily made using 3DE. In addition, real-time 3D transesophageal echocardiography has been proven to be more accurate than two-dimensional (2D) techniques in identifying specific MV abnormalities associated with complex diseases. Moreover, real-time 3DE offers the advantage of shorter fluoroscopy and radiation times throughout PMBV. This article reviews the use of 3DE during PMBV in light of the most recent literature and based on expertise and discusses the pros and cons of 3DE, with emphasis on its superiority to conventional 2D echocardiography.

Sleep Inversion and The Left Ventricular Systolic Function

Abstract Background Sleep inversion is sleeping during the day and waking up at night; a depart from the normal sleeping time between 10:00 PM to 5:00 AM. The aim of this study was to detect subtle changes in left ventricular (LV) systolic function caused by sleep inversion using strain imaging in young healthy individuals free of cardiovascular risk factors. Methods 100 healthy persons (18 to 35 years of age) with an inverted sleep pattern, and a normal LV systolic function by conventional 2D echocardiography were compared with 100 healthy individuals from the same age group with normal sleep timings. Conventional and speckle tracking echocardiography were performed. Results Male gender, smoking, less exercise, social media overuse, and junk food were significantly more common in the sleep inversion group. They had lower mean GLS than the controls (-20.90% ± 3.45 vs -22.87% ± 3.67, p &amp;lt; 0.0001). By multivariate analysis, sleep inversion was found to be independently associated with low GLS (Odds ratio: 2.02, 95% confidence interval (CI): 1.07–3.82, p = 0.03). Conclusion Sleep inversion is associated with subclinical left ventricular systolic dysfunction detected by speckle tracking in young healthy individuals. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Prognostic impact of right ventricular strain in isolated severe tricuspid regurgitation

Abstract Background Right ventricular (RV) systolic function is determinant in the evaluation of patients with severe tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is challenging. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detecting subclinical RV dysfunction. Purpose This study was aimed to evaluate the prognostic value of RV strain parameters in consecutive stable patients with severe TR. Methods Consecutive patients in stable clinical status with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Patients with previous episodes of heart failure or scheduled for TV intervention were excluded. RV systolic function was measured with conventional echocardiographic indices (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE], DTI S wave [`S]) and with Speckle-tracking echocardiography (STE) derived automatic peak global and free wall longitudinal strain (RV-GLS and RV-FWLS respectively) using the EPIQ system (Philips Medical Systems, Andover, Massachusetts). A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. The interobserver variability of RV strain was assessed in 20 randomly selected patients. Results A total of 176 patients were included in this study. Strain parameters detected higher percentage of RV dysfunction compared to conventional indices (figure 1). After a median follow-up of 28 months (IQR: 15–48 months), n=65 patients (37%) reached the combined endpoint. 65 (37%) were admitted for right heart failure and 8% of the population (n=14) died. Cumulative event-free survival was significantly worse in patients with impaired RV-GLS and RV-FWLS. Conventional indices of RV systolic function were not associated with outcomes (p&amp;gt;0.05 for all). In a multivariable analysis (in a model including NYHA class, BNP values, biplane VC, RV end-diastolic area, and RV-FWLS), RV-FWLS was an independent predictors of heart failure and CV mortality (figure 1 and 2; LR χ2: 40.2, p&amp;lt;0.001). Inter-observer agreements for RV strain values were high (intraclass correlation coefficient for RV-GLS and RV-FWLS, r=0.96 and r=0.98 respectively) Conclusion Clinical outcomes demonstrate that RV strain parameters are superior to conventional indices of RV function in patients with isolated ≥ severe TR and absence of previous episodes of heart failure. Among all parameters of RV function, RV-FWLS is the strongest independent predictor of mortality and HF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto Carlos III

Right ventricular quantification using 3D echocardiography: a comparison with CMR

Abstract Background Volumetric and functional right ventricular (RV) indices such as ejection fraction (EF) and global strains are known independent predictors of adverse cardiovascular events. While cardiac magnetic resonance (CMR) imaging remains the reference standard for volume quantification, echocardiography is more accessible and allows for rapid ventricular assessment. Compared to conventional 2D echocardiography, 3D echocardiography (3DE) enables full volume acquisitions and the ability to circumvent geometric assumptions. Given the complexity of RV geometry and sensitivity to image plane positioning, this advantage offers the potential to obtain more accurate diagnostic measurements. Purpose Tools for RV analysis in 3DE have been less extensively studied compared to those for the left ventricle (LV). We sought to quantify discrepancies in RV indices derived from 3DE and CMR. Methods Transthoracic real-time 3DE and cine CMR imaging were performed in 20 prospectively recruited participants (12 patients with acquired cardiac disease and 8 healthy controls), &amp;lt;1 hour apart. Dynamic 3D biventricular models were constructed semi-automatically from CMR by identifying fiducial landmarks, correcting in-plane breath-hold mis-registrations, and interactively fitting contours to the endocardial and epicardial borders on long- and short-axis slices. For 3DE, right ventricular endocardial models were created by fitting contours on 2D image planes resampled from the 3D volume at end-diastole and end-systole, which were subsequently tracked over one cardiac cycle (Figure 1). RV indices including end-diastolic volume (EDV), end-systolic volume (ESV), EF, global longitudinal strain (GLS), and global circumferential strain (GCS) were calculated from the 3DE- and CMR-derived 3D geometric models and compared. Paired-sample t-tests were performed to identify statistically significant differences (where P&amp;lt;0.05), and intraclass correlation coefficients (ICC) for absolute agreement were computed to assess the reliability for each measurement. Results Differences (mean ± SD) in RV indices between 3DE and CMR, with corresponding ICCs are presented in Table 1. Statistically significant differences in RV EDV, ESV, EF, and GLS were observed, with 3DE consistently underestimating volumes and overestimating function when compared to CMR. Although a statistically significant difference in RV GCS was not observed, a low ICC score indicated poor reliability. Conclusions Volume underestimation in RV indices between 3DE and CMR were found to be larger than those previously reported for the LV, which is likely due to the increased geometric complexity and surface area to volume ratio for the RV. Moreover, 3DE tends to overestimate RV function in terms of EF and GLS, which may impact treatment pathways if used in a clinical setting. Recognising systematic differences between modalities reinforces the need to further develop 3DE technologies for more accurate RV quantification. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Research Council (HRC) of New Zealand;National Heart Foundation (NHF) of New Zealand

3D Approaches in Complex CHD: Where Are We? Funny Printing and Beautiful Images, or a Useful Tool?

Echocardiography, CT and MRI have a crucial role in the management of congenital heart disease (CHD) patients. All of these modalities can be presented in a 2D or a 3D rendered format. The aim of this paper is to review the key advantages and potential limitations, as well as the future challenges of a 3D approach in each imaging modality. The focus of this review is on anatomic rather than functional assessment. Conventional 2D echocardiography presents limitations when imaging complex lesions, whereas 3D imaging depicts the anatomy in all dimensions. CT and MRI can visualise extracardiac vasculature and guide complex biventricular repair. Three-dimensional printed models can be used in depicting complex intracardiac relationships and defining the surgical strategy in specific lesions. Extended reality imaging retained dynamic cardiac motion holds great potential for planning surgical and catheter procedures. Overall, the use of 3D imaging has resulted in a better understanding of anatomy, with a direct impact on the surgical and catheter approach, particularly in more complex cases.

Association of MMP1 and MMP3 haplotypes with myocardial infarction and echocardiographic parameters of the left ventricle.

BackgroundMyocardial infarction (MI) leads to ischemia and afterward to left ventricular (LV) remodeling. Matrix metalloproteinase−1 (MMP1) and −3 (MMP3) belong to the family of endopeptidases and together they can dissolve most of the components of the extracellular matrix. MMP1 and MMP3 variants have been investigated solely in association with ischemic heart disease and LV dysfunction, but not in haplotype. The aims of this study were to investigate the association of haplotypes inferred from MMP1 rs1799750 (−1607 1G/2G; NC_000011.9:g.102670497del) and MMP3 rs35068180 (−1612 5A/6A; NC_000011.9:g.102715952dup) with MI and their effect on the change in echocardiographic parameters of LV structure and function in patients within 6 months after MI.MethodsThe study included 325 patients with the first MI and 283 healthy controls. Gene variants were detected by PCR‐RFLP method. Parameters of LV structure and function were assessed by conventional 2D echocardiography, 3–5 days and 6 months after the first MI, on a subgroup of 160 patients. Haplotype analysis was performed with Thesias software.ResultsHaplotypes 2G‐5A and 1G‐6A were significantly and independently associated with MI compared with the reference haplotype 2G‐6A (adjusted, p = 0.009 and p = 0.026, respectively). After Bonferroni correction for multiple testing, MMP1 and MMP3 haplotypes lost their association with the change in LV long diameter and stroke volume within 6 months after MI.Conclusion MMP1 and MMP3 haplotypes are strongly associated with MI. Further studies are needed to validate this result and to examine their association with echocardiographic parameters of LV structure and function after MI.

SST2 Level at Decompensated Chronic Heart Failure in Patients with Dilated Cardiomyopathy

The purpose of the study was to evaluate the relationship between clinical and functional changes and sST2 levels in patients with dilated cardiomyopathy (DCM) admitted to the hospital due to decompensated chronic heart failure (CHF). Methods and Results: The study involved 64 DCM patients with clinical signs of decompensated CHF. According to the sST2 level, the patients were divided into two groups. Group 1 included 30 patients with sST2 level &lt;35ng/ml; Group 2 included 34 patients with sST2 level ≥35ng/ml. All patients underwent the following examinations: collection of anamnestic data, physical examination, general clinical and laboratory blood tests, 12-lead ECG, conventional 2D echocardiography in M- and B-modes, the 6MWT, and the assessment of the quality of life according to the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The serum level of sST2 was determined by enzyme immunoassay using the Presage ST2 Assay. The duration of CHF was significantly longer in Group 2 than in Group 1(48.7±6.5 mth versus 29.6±7 mth P&lt;0.05), and the number of hospitalizations per year was more frequent. Group 2 patients were characterized by lower blood pressure levels and high heart rate (P&lt;0.05). At the same time, the 6MWT value was lower and MLHFQ score was higher in Group 2 than in Group 1 (P&lt;0.001 in both cases). In Group 1, LVEF was significantly higher and LVM was significantly lower than in Group 2 (P&lt;0.001). All in all, Group 2 patients had more pronounced disorders in LV systolic dysfunction. The correlation analysis revealed an inverse correlation between the sST2 level and 6MWT (r=-0.69, P&lt;0.01), as well as LVEF (r=-0.26, P&lt;0.01). Statistically significant direct correlations were found between the sST2evel and the size and volume of the LV cavities. Conclusion: sST2 is a clinically relevant biomarker that reflects pathophysiological processes and provides prognostic information in the setting of DCM, especially in patients with HF.

Ventricular-Arterial Uncoupling and Hypertension Mediated Diastolic Dysfunction.

The increase in the pulsatile component of left ventricle afterload is suspected to cause a mismatch between the left ventricle (LV) and the vascular tree. Todemonstrate that ventricular-arterial uncoupling is frequently present in the development of LV hypertrophy (H) and diastolic dysfunction (DD) in hypertension (HBP). Observational study, HBP patients with ejection fraction >54%. Conventional 2D echocardiography and tissue Doppler performed following imaging guidelines. LV end systolic elastance (Ees), the effective arterial elastance (Ea), and ventricular-arterial coupling (VAC) measured by Chen single beat method. 288 patients, mean age 56.3±12.5 years and 168 patients (58.3%) males. Mean LV mass index was 87.2±20.4 grs/m2 and frequency of LVH 20.1% (58 patients). The mean VAC was 0.54±9.23. LV Stroke volume, stroke work and systolic stress were 46.2±10.3 cc/m2, 91.4±22.2 g-min/m2, and 57±14.6 dynes/cm2 in quartile 1, and 33.5±6.6 cc/m2, 65.5±15.2 g-min/m2, and 77.8±17.1 dynes/cm2, in quartile 4, respectively (p<0.001). Peripheral resistance index was 3349±1072 and 4410±1143 dynes*s/cm-5/m2 quartiles 1 vs. 4 (p<0.005). The frequency of LVH was 31.9% in quartile 1 and 11.3% in quartile 4 (p<0.005) and LVH or DD was 37.5% and 12.7%, respectively (p<0.001). Stroke volume and stroke work were significantly increased while systolic stress and peripheral resistance index were significantly reduced in patients with worst VAC. Ventricular-arterial uncoupling is mostly caused by an increase in Ees rather than by an elevation of Ea. LVH or DD are more frequent in the worst cases of ventricular-arterial uncoupling.

Exploration of the Utility of Speckle-Tracking Echocardiography During Mechanical Ventilation and Mechanical Circulatory Support.

OBJECTIVE:This narrative review aims to discuss the potential applicability of speckle-tracking echocardiography (STE) in patients under mechanical ventilation (MV) and mechanical circulatory support (MCS). Both its benefits and limitations were considered through critical analyses of the current available evidence.DATA SOURCES AND STUDY SELECTION:A literature search was conducted in PubMed and Excerpta Medica Database indexed databases (2012–2021). In addition, the reference lists of all selected studies were manually scanned for further identification of potentially relevant studies.DATA EXTRACTION:The terms “Speckle-Tracking Echocardiography,” “Mechanical Ventilation,” “Mechanical Circulatory Support,” “Extracorporeal Membrane Oxygenation,” “Ventricular Assist Devices,” and “Left Ventricular Unloading Devices” were searched for the identification of relevant articles for narrative synthesis.DATA SYNTHESIS:STE is a well-established post-processing method of analyzing myocardial function, with potentially greater clinical utility than conventional 2D echocardiography. STE has been incorporated into the guideline recommendations for both the diagnostic and prognostic evaluations of myocardial and valvular pathologies. However, the potential of STE application within critical care settings has not yet been fully realized. Its utility in the assessment of patients undergoing MV and MCS is substantial. Specifically, it may serve as an ideal modality in the assessment of subtle changes in cardiac function. In the limited number of studies reviewed, STE was consistently a more sensitive marker of myocardial functional change, compared with traditional markers of 2D and Doppler parameters during changes in MV and MCS.CONCLUSIONS:Although current evidence is extremely limited, STE strain is suggested to be a more sensitive and reproducible parameter of myocardial function than conventional echocardiographic parameters and may have value in the assessment of patients undergoing MV and MCS in critical care settings. Further studies in larger populations are required to elucidate STE’s prognostic capability and its value as a point-of-care tool in guiding clinical practice for subjects under MV and MCS.

Association between brain natriuretic peptide and cardiac dysfunction in hypertensive pregnancy disorders.

The aim of this work is to identify the correlation between serum brain natriuretic peptide (BNP) and left ventricle (LV) systolic and diastolic function in hypertensive pregnancy disorders (HPD) through echocardiographic parameters. Eighty-seven pregnant patients were included, 23 with normotensive pregnancy (NP), 28 with gestational hypertension (GH) and 36 with preeclampsia (PE). Conventional 2D echocardiography was used to evaluate systolic and diastolic function such as E/a, E/e', LV mass index, LV ejection fraction, as well as left atria (LA) diameters, LA indexed volume, LV strain and LA strain (LAS). Brain natriuretic levels (BNP) blood levels were also determined. The serum levels of BNP were higher in patients with PE [median (interquartile range, IQR)] 189 (142-215) pg/ml and GH 105 (46-162) pg/ml compared to NP 23 (9-33) pg/ml, (p=0.001). BNP levels had a negative correlation with LAS (Rho=-0.79, p<0.001). Preeclampsia patients had lower LAS [median (IQR)] 22% (20%-24%) compared to the GH group 23% (20%-24%) and NP 35% (34% -35%), p=0.001. Classification and Regression Trees multivariate analysis found patterns that define trends to form mutually excluding homogeneous groups such as: a) First parameter that separates 2 groups is septal e>8.2 or<8.2b), BNP serum levels above 89pg/ml, and c) LAS increases the discriminatory performance to detect and define the diastolic dysfunction or not. At least one third of women with HPD had moderate diastolic dysfunction. The degree of diastolic dysfunction was negatively correlated with serum BNP levels and severity of HPD. LAS increase discriminatory performance to identify diastolic dysfunction in HPD.

Left ventricular dimensions and mass measurement from 3D echocardiography: are we there yet?

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Research Council (HRC) of New Zealand and National Heart Foundation (NHF) of New Zealand Introduction—Echocardiographic measures of left ventricular (LV) structure and size, including LV wall thickness and LV end-diastolic dimension (LVID), provide important information in the assessment of patients with heart disease. For example, LV mass is a predictor of outcome for patients with hypertension and LVID is a predictor of cardiac resynchronisation response in patients with heart failure. Advances in 3D echocardiography (3DE) have enabled full-volume acquisitions, which overcome geometric assumptions present in conventional 2D echocardiography (2DE), providing a more accurate representation of cardiac geometry. Although numerous validation studies have been performed for 3DE-derived LV volumes, comparisons of LV dimension by 3DE against established methods are limited. Purpose—We sought to compare routine LV dimension measurements between 3DE and 2DE, with validation using cardiac magnetic resonance (CMR) imaging. Methods—Transthoracic echocardiography (2D and 3D) and cine CMR imaging were performed in 62 prospectively recruited participants (47 healthy controls, 9 patients with LVH, 6 patients with aortic regurgitation), &amp;lt;1 h apart. 2DE LV dimension measurements (interventricular septum [IVS], posterior wall thickness [PWT], and LVID) were taken at end-diastole from the parasternal long axis, and mass was calculated using the linear method based on ASE/EACVI guidelines. For 3DE, 3D geometric models of the LV were constructed by interactively fitting surfaces to the endocardium and epicardium using previously validated software, from which corresponding LV dimension measurements and mass were extracted. Measurements were obtained from CMR by a similar 3D geometric modelling process. Results—Differences (mean ± SD) in LV dimension measurements between the three modalities and intraclass correlation coefficients (ICC) are presented in Table I. When compared with CMR, 3DE exhibited higher agreement in terms of LVID and mass than 2DE, but lower agreement in wall thickness measurements. Statistically significant differences were found between 2DE and 3DE for PWT, LVID, and mass, as well as 2DE and CMR for LVID and mass (where P &amp;lt; 0.01 for a paired sample t­-test, marked with an asterisk). Meanwhile, there were no statistically significant differences between 3DE and CMR for IVS, PWT, LVID, or mass. Conclusions—Our results demonstrate that 3DE is superior to 2DE in terms of LVID and mass quantification, exhibiting good agreement with CMR. 3DE exhibited moderate and poor agreement for IVS and PWT, respectively, with both 2DE and CMR, likely due to the lower spatial resolution of 3DE. Further advances in 3DE image quality and analysis tools are therefore needed to improve accuracy of wall thickness measurements. Since 2DE imaging plane and probe positioning can result in oblique measurement and underestimation of LVID, the assessment of LVID and mass by 3DE is likely to lead to more accurate diagnostic and prognostic outcomes. Abstract Table 1

Routine use of automated strain analysis and 3D echocardiography provides a more comprehensive assessment of cardiac chambers than conventional 2D echocardiography and is time-saving

Abstract Funding Acknowledgements Type of funding sources: None. Background. In most laboratories three-dimensional echocardiography (3DE) and longitudinal strain (Lstrain) analysis are not part of the routine studies. Although these modalities have been shown to provide additional clinical information and prognostic value compared to conventional two-dimensional echocardiography (2DE), their acquisition and analysis are perceived as being time-consuming. Recently, new automated tools have been developed to perform accurate, fast and reproducible analyses of heart chambers’ geometry and function. However, their cost-effectiveness when compared to conventional 2DE remains to be demonstrated. Aim. We designed a prospective, multicenter, observational study aimed to compare the time required for the acquisition and analysis of conventional transthoracic 2DE vs advanced echocardiography (AEcho, i.e. 3DE+ Lstrain) for the assessment of cardiac chambers and myocardial mechanics. Methods. According to current guidelines, 196 consecutive patients referred for clinically indicated echocardiography underwent complete 2DE and Doppler echocardiography. In addition, 3DE datasets of the left atrium (LA), left and right ventricle (LV, RV) were acquired using automated 3DE software package (Heart Model). Acquisition time for both 2DE and 3DE images were recorded. Conventional 2DE analyses of LA (biplane volume), LV (biplane volumes and mass) and RV (both linear dimensions, areas, and longitudinal function) were performed following current guidelines, and the time required for acquisition and analysis was recorded. The time spent for AEcho analysis (both 3DE volumetric analysis and Lstrain of LA, LV and RV) was also recorded. Results. Feasibility of AEcho was 86% (169 patients). The additional time for 3D dataset acquisition over conventional 2DE was 38 ± 0.16 sec. Quantitative analysis of the cardiac chambers by 2DE required an average of 5.55 ± 1.51 min vs 4.25 ± 1.23 min using AEcho (p &amp;lt; 0.001). Total time for both 3D dataset acquisition and AEcho assessment was 5.03 ± 1.28 min vs 5.55 ± 1.51 min of 2DE analysis alone (p &amp;lt; 0.001). Globally, AEcho provided a more comprehensive assessment of heart chambers than 2DE (Table). Moreover, the time spent for 3DE dataset acquisition and AEcho analysis on top of standard 2DE acquisition was significantly shorter compared to the 2DE acquisition and analysis (18:50 ± 4.23 vs 19:42 ± 4.24 min, p &amp;lt; 0.001) (Table). Conclusions. Our data showed that the use of new AEcho automated tools are highly feasible resulting in significant time-savings compared to standard 2DE evaluation, while providing significant additional information. Abstract Table

PREDICTIVE ROLE OF INFARCT RELATED ARTERY IN ACUTE RIGHT VENTRICULAR INFARCTION DIAGNOSED USING ELECTROCARDIOGRAPHY

Right coronary artery (RCA) emerged as infarct related artery (IRA) in patients with right ventricular myocardial infarction (RVMI), which is followed by some degree of RV dysfunction. The aim of our study was to identify significant predictors of IRA among angiographic and/or echocardiographic data of RV dimension and/or function in patients with acute RVMI. Out of 122 hospitalized patients with acute inferior myocardial infarction, on the basis of ECG criteria RVMI was diagnosed in 58/47.5% patients. Coronary angiography was applied in 52/89,6% immediately after admission and conventional 2D echocardiography was performed in all referred patients in order to assess right heart dimensions and function according to the professional association recommendations. RCA emerged as IRA in 49/84,5 % of patients with echocardiographicaly diagnosed RVMI. Patients with RCA stenosis/occlusion had 4.9 times higher risk for RVMI presence (OR=4.941; 95%CI: 1.727-14.136; p=0.003) than those without and had significantly worse echocardiographic assessed RV global and/or regional systolic function. Logistic stepwise regression analysis confirmed the significant role of&nbsp; enlarged RV dimension (OR=1.1; 95%CI: 1.023-1.182; p=0.010), RCA stenosis/occlusion presence (OR=4.8; 95%CI: 1.649-14.199; p=0.004) and/or LAD stenosis/occlusion absence (OR=0.18; 95%CI: 0.067-0.476; p=0.001) in prediction of RVMI. The optimal sensitivity of the model was 90% and specificity 75%.&nbsp;RCA and conversely lack of LAD stenosis/occlusion presence along with some of the echocardiographic parameters showing RV dysfunction increased the odds for RVMI. Applying immediate and complete reperfusion of RCA is of a great importance for recovery of RV function. Key words: right myocardial infarction, right coronary artery, right ventricular dysfunction, reperfusion.

Is conventional cardiac examination adequate for obese pregnant women? A prospective case–control study

ObjectiveObesity in pregnancy shows short- and long-term adverse effects for both mother and baby. We aimed to investigate the effects of obesity on cardiac functions in the third trimester of pregnancy.Materials and methods: A prospective case–control study where the pregnant women at the third trimester of pregnancy were divided into two groups: obese (BMI≥30) and the controls (BMI<30). All participants underwent conventional 2D and speckle-tracking echocardiography, while structural and functional cardiac parameters were measured. The unpaired t-test or the Mann-Whitney-U test were used to compare values between the two groups. p ≤ 0.05 was outlined to be statistically significant. ResultsForty-one obese pregnant women and 41 healthy and normal-weight pregnant controls were recruited. The mean BMI was 24.6 ± 2.4 kg/m2 in the controls and 38.5 ± 5.4 kg/m2 in the obese group. SV was significantly higher in obese patients (p = 0.02). SVI was markedly lower in the obese group (p < 0.01). CO and Cardiac Index were significantly higher in obese patients compared to the controls (p < 0.01). TVRI was significantly higher in the obese group than the controls. EF was similar between the two groups (p = 0.33). LVM and LVMI were significantly higher in obese patients than the controls (p = 0.024 and p = 0.01). Diastolic dysfunction was present in 3 (7.3%) controls; 21 (51.2%) of the obese women demonstrated diastolic dysfunction, and it was significantly higher than the controls (p < 0.01). LV-GLS and LV-GCS were substantially lower in the obese group (p < 0.01). RV-FAC and RV-GS were markedly lower in the obese group (p < 0.01). TAPSE was similar in obese and control groups (p = 00.17). ConclusionObesity in pregnancy is associated with increased subclinical systolic and diastolic dysfunction, which cannot be detected by standard 2D methods.

Role of speckle tracking in precise localization of accessory pathway in Wolff-Parkinson-White syndrome

Background: The non-Doppler echocardiographic technique known as two-dimensional speckle tracking echocardiography (2D-STE) has been demonstrated to help assess dyssynchrony and allow quantification of cardiac deformity and timing in 2D greyscale images. This study evaluated the 2D speckle tracking role in the accessory pathway (AP) localization compared to the electrophysiology study (EPS) as the gold standard technique. Methods: This study was performed on patients with evident Wolff-Parkinson-White (WPW) syndrome who were recommended to undergo EPS and ablation. Patients were recruited based on results from the resting ECG, clinical history of recurrent palpitations, or an ECG with confirmed bouts of atrioventricular reentrant tachycardia (AVRT). The patients were evaluated using electrocardiography, conventional 2D echocardiography, and 2D-STE and were assessed for the possibility of ablation. Results: Thirteen patients were included (seven males and six females) with a mean age of 29.23 ± 9.3 years. All patients had a negative family history of WPW syndrome. ECG revealed that AP localization was posteroseptal in 4 patients (30.8%), anteroseptal in 3 (23.1%), right lateral in 2 (15.4%), left lateral in 1 (7.7%), anterolateral in 1 (7.7%), right posterior in 1 (7.7%), and left posterior in 1 (7.7%).