Echocardiographic Measurements Research Articles

Gestational arsenite exposure alters maternal postpartum heart size and induces Ca2+-handling dysregulation in cardiomyocytes.

Cardiovascular disease is the leading cause of mortality in the US. Studies suggest a role for environmental exposures in the etiology of cardiovascular disease, including exposure to arsenic through drinking water. Arsenic exposure during pregnancy has been shown to have effects on offspring, but few studies have examined impacts on maternal cardiovascular health. While our prior work documented the detrimental effect of arsenic on the maternal heart during pregnancy, our current study examines the effect of gestational arsenic exposure on the maternal heart postpartum. Timed-pregnant wild-type (C57BL/6J) mice were exposed to 0, 100 or 1000 µg/L sodium arsenite (NaAsO2) via drinking water from embryonic day 2.5 until parturition. Postpartum heart structure and function was assessed via transthoracic echocardiography and gravimetric measurement. Hypertrophic markers were probed via qRT-PCR and western blot. Isolated cardiomyocyte Ca2+-handling and contraction were also assessed, along with the expression of with Ca2+-handling and contractile proteins. Interestingly, we found that exposure to either 100 or 1000 µg/L sodium arsenite increased postpartum heart size at postpartum day 12 vs. non-exposed postpartum controls. At the cellular level, we found altered cardiomyocyte Ca2+-handling and contraction, along with expression changes of key contractile proteins, including α-Actin and cardiac myosin binding protein C (cMyBP-c). Together, these findings suggest that gestational arsenic exposure impacts the postpartum maternal heart, possibly inducing long-term cardiovascular changes. Furthermore, these findings highlight the importance of reducing arsenic exposure during pregnancy, and the need for more research on the impact of arsenic on maternal heart health and adverse pregnancy events.

Subclinical patterns of cardiac involvement by transthoracic echocardiography in individuals with mild initial COVID-19.

The aim of this study was to evaluate the subclinical patterns and evolution of cardiac abnormalities via transthoracic echocardiography (TTE) in patients with mild initial COVID-19 illness. A total of 343 infected individuals (163 males; age 44 (interquartile range, IQR 35-52) years) years) underwent serial TTE assessments at a median of 109 (interquartile range (IQR), 77-177) and 327 (276-379) days after infection. Compared with those of non-COVID-19-infected controls (n = 94, male n = 49), baseline systolic (LVEF, TAPSE) and diastolic function (e', a', E/e') were significantly different in infected participants (p < 0.05 for all). Compared with baseline assessments, there was a reduction in global longitudinal strain (GLS) and an increase in the E wave, E/A ratio and E/e' at follow-up. At baseline, symptomatic participants had a lower LVEF and TAPSE and increased IVRT, e' and E/e'. At follow-up, symptomatic patients had a lower LV end-diastolic diameter (LVEDd). Symptoms were independently associated with E/e' at baseline (OR (95% CI) 1.45 (1.12-1.87), p = 0.005). Symptoms at follow-up were associated with LVEDd, measured either at baseline (OR: 0.91 (0.86, 0.96), p < 0.001) or follow-up (OR (95% CI) 0.91 (0.86-0.96), p < 0.001). There were significant associations for GLS and troponin and E/e' with CRP and NTproBNP at baseline. In the present cohort of COVID-19-infected individuals with mild initial illness, echocardiographic measurements revealed significant yet subclinical differences in systolic and diastolic function compared with controls, as well as between individuals with cardiac symptoms and those without. All the measured differences were small in magnitude and thus unlikely to be detectable clinically at the individual level.

External validation of automated deep-learning based echocardiogram analysis

Abstract Background The use of artificial intelligence (AI) in echocardiography is constantly expanding. Several AI algorithms now enable fully automated measurement of echocardiographic parameters, which can potentially reduce measurement variability and increase efficiency. These AI algorithms have demonstrated accuracy comparable to conventional human-based measurements. However, to adopt automated AI echocardiography analysis for routine use, we need a deeper understanding of its performance compared with that of human expert readers. Purpose This study aims to perform a real-world external validation of a commercial, fully automated AI algorithm by comparing its performance standard to echocardiographic measurements done by human experts. Methods We retrospectively analyzed 889 consecutive hospitalized patients who underwent a clinically indicated transthoracic echocardiographic study. Each study was performed by experienced cardiac sonographers and reviewed by expert echo cardiologists. All studies were also analyzed by a commercial, fully automated AI software (Us2.AI). We analyzed the correlation between standard echocardiographic parameters measured by human experts to those measured by the AI algorithm. Results Of the 889 patients, 731 (82%) had sufficient echocardiographic data to be included in the analysis (mean age 68±16, 46% Female). As shown in Table 1, the measures with the strongest correlation were E wave velocity (r=0.96, P&amp;lt;0.001), E/e' ratio (r=0.86, P&amp;lt;0.001), and systolic pulmonary artery pressure (r=0.88, P&amp;lt;0.001) whereas posterior wall thickness and left ventricular ejection fraction (LVEF) had lower correlation coefficients (r=0.52 and r=0.61, respectively, both P&amp;lt;0.001). On Bland-Altman plot (Figure 1), mean AI-obtained LVEF values were significantly higher compared to human-estimated LVEF values with a mean difference of 5.8. This discrepancy was specifically evident in cases where the human-based LVEF was 45% or higher. Conclusion In this external validation study, AI-based echocardiographic measurements showed a strong correlation with human-based measurements. LVEF values obtained by AI tended to be higher than human LVEF estimation. Correlation of echocardiographic measure Bland Altman for LV EF

Correlation of pulmonary artery systolic pressures derived from echocardiography and hemodynamic catheterization in patients with tricuspid regurgitation: a large single-center study

Abstract Introduction Echocardiography is the recommended modality for non-invasive assessment of pulmonary pressures. However, in patients with severe tricuspid regurgitation (TR), the reliability of echocardiographically derived systolic pulmonary artery pressure (sPAP) is questioned. Limited data exists on the correlation between echocardiography and right heart catheterization (RHC) in selected group of patients with severe TR. Purpose To evaluate the correlation between echocardiographic and RHC measurements for sPAP in patients with varying TR severity. Method Patients who underwent echocardiography and RHC within three days at a large single referral center were retrospectively included. Exclusion criteria included incomplete echocardiographic and RHC data, ≥moderate pulmonary stenosis, low-quality images, and pregnancy. Echocardiographic sPAP was calculated using simplified Bernoulli equation. Echocardiographic right atrial pressure (RAP) was assessed by evaluating inferior vena cava (IVC) dimension and collapsibility. A difference of ≥10 mmHg between the two modalities for sPAP was considered clinically significant. Results Of 3696 patients included, mean age was 64±14 years, 1689 (46%) were females, 1659 (45%) had systemic hypertension, and 582 (16%) had atrial fibrillation. TR was &amp;lt;moderate in 2475 (67%) patients, moderate in 499 (14%), moderate-severe in 277 (7%), and severe in 445 (12%). Pulmonary hypertension (PH) was diagnosed in 3079 subjects (83%). A good correlation was found between sPAP derived by echocardiographic and RHC in the whole cohort (correlation coefficient (LCC) 0.79, CI 0.78-0.80), in severe TR subgroup (LCC 0.78, CI 0.75-0.82), and in severe TR with PH subgroup (LCC 0.76, CI 0.71-0.79). The mean echocardiographic misestimation for sPAP in severe TR was 3.97 mmHg (CI -5.24 to -2.71). The correlation between the two modalities for RAP was moderate in the whole cohort (LCC 0.59, CI 0.57-0.61) and fair in severe TR (LCC 0.35, CI 0.27-0.42). A clinically significant difference between the two modalities for sPAP was found in 1504 patients (41%), predominantly due to the right ventricle-right atrium gradient misestimation, rather than RAP misestimation, in patients with no PH (67% vs 33%), patients with mild-moderate PH (mean Pulmonary Artery Pressure (mPAP) 21-34 mmHg) (67% vs 33%) and severe PH (mPAP ≥35 mmHg) (76% vs 24%). Conclusion The correlation between echocardiographic and RHC measurements is good for sPAP, even in severe TR patients, while it is only fair to moderate for RAP. A clinically significant difference between echocardiographic and RHC sPAP is more commonly observed in patients with PH, with right ventricle-right atrium gradient misestimation being the most common cause.

Acute alterations in blood lactate in the setting of transient stress induced myocardial ischaemia

Abstract Background An elevation in resting venous blood lactate levels ([La-]b) in conditions of myocardial hypoperfusion is associated with adverse prognosis and survival. This investigation aimed to assess changes in venous [La-]b levels induced by dobutamine stress in the presence and absence of myocardial ischaemia and adverse outcomes at 1-year. Methods 404 consecutive patients (mean age 70±10 years, 243 male) reporting chest pain underwent dobutamine stress echocardiography and were categorised as ischaemic (IS) or non-ischaemic (NI) responders. Conventional and global longitudinal strain (GLS) echocardiographic measures were recorded at rest. Venous [La-]b samples were acquired at rest, peak stress and 1, 3, 5 and 10-minutes into recovery using a commercially available Lactate Pro 2 device. Results There were no significant differences in [La-]b concentrations between IS (1.75±0.76 mmol×L-1) and NI (1.73±0.60 mmol×L-1) responders at baseline (p=0.592). However, [La-]b concentrations were significantly greater at peak stress (1.83±0.57 vs. 1.68±0.60 mmol×L-1), 1 (1.90±0.56 vs. 1.73±0.71 mmol×L-1), 3 (1.97±0.56 vs. 1.73±0.71 mmol×L-1), 5 (1.98±0.60 vs. 1.74±0.70 mmol×L-1), and 10-minutes (2.01±0.63 vs. 1.76±0.71 mmol×L-1) into recovery between IS and NI responders (all p&amp;lt;0.001), respectfully. GLS was significantly lower in IS compared to NI responders (-15.5±2.9 vs -16.2±2.7%, p=0.02) at baseline. In patients who experienced an adverse cardiac event during 1-year of follow-up, GLS (-14.4±2.7 vs -16.1±2.8%, p&amp;lt;0.001) and [La-]b concentrations were significantly lower at baseline (1.54±0.55 mmol×L-1 vs. 1.78±0.70 mmol×L-1, p=0.02), as were [La-]b concentrations at 5 (1.68±0.55 mmol×L-1 vs. 1.88±0.68 mmol×L-1, p=0.04) and 10-minutes (1.70±0.56 mmol×L-1 vs. 1.93±0.71 mmol×L-1, p=0.02) into recovery compared to patients who did not experience an adverse event, respectively. GLS (HR 1.21; 95% CI 1.11 to 1.33, p&amp;lt;0.001) and [La-]b concentrations at 10-minutes into recovery (HR 0.54; 95% CI 0.33 to 0.85, p=0.01) were significant independent predictors of an adverse event. Conclusions Transient myocardial ischaemia is associated with a significant elevation in [La-]b concentrations, which extends into the recovery period, compared to NI responders. A blunted metabolic response to dobutamine stress and attenuated longitudinal myocardial mechanics are independently associated with short-term adverse events.

Comparison of quantitative echocardiographic parameters for grading of mitral regurgitation severity for prediction of clinical outcome

Abstract Introduction Current recommendations favour the use of quantitative parameters for the assessment of mitral regurgitation (MR) severity and the effective regurgitant orifice area (EROA) derived from the proximal isovelocity surface area (PISA) method has been demonstrated as a predictor of outcome. Purpose The aim of our study was to compare the long-term predictive value of quantitative echocardiographic parameters, derived from the PISA method and volumetric method on clinical endpoints. Methods We retrospectively analysed 298 patients who consecutively underwent echocardiographic examination at out department in 2018 and had been diagnosed with more than mild MR. From the echocardiographic measurements we calculated the quantitative parameters (EROA, regurgitant volume (Rvol) and regurgitant fraction (RF)) by the PISA method and volumetric method (based on the Rvol calculated as a difference between total left ventricular stroke volume derived from the Simpson’s biplane planimetry and forward stroke volume assessed by the pulsed-wave Doppler left ventricular outflow tract method). The clinical outcome was death from any cause, hospitalization due to heart failure or mitral valve intervention in the period from the echocardiographic examination to the end of 2022. Results The study cohort comprised 169 (56%) patients with secondary MR, 103 (35%) with primary MR and 26 (9%) with combined etiology. Clinical endpoints were observed in 198 (66%) patients. Median time to the event was 732 (121-1578) days. Quantitative parameters by the PISA method better predicted the clinical outcome compared to quantitative parameters by the volumetric method (Figure A). RF-PISA had the biggest area under the curve (AUC 0.633, p &amp;lt; 0.001), followed by the EROA-PISA (AUC 0.626, p &amp;lt; 0.001), while the predictive values of quantitative parameters by the volumetric method were not significant (EROA: p= 0.109, Rvol: p=0.153, RF: p=0.156). By the PISA method, patients with RF≥50% had more adverse outcome compared to those with RF&amp;lt;50% (Figure B). By the volumetric method, however, the outcome was similar for both patients with RF≥50% or &amp;lt;50% (Figure B). In our cohort, the best cut-off value for the prediction of the clinical event was RF-PISA &amp;gt;46% (sensitivity 48%, specificity 76%) and EROA-PISA &amp;gt; 0.24 cm2 (sensitivity 41%, specificity 78%). Conclusions Quantitative parameters for grading MR severity by the PISA method provide better diagnostic accuracy for predicting the clinical outcome in comparison to quantitative parameters by the volumetric method. RF-PISA turned out as a good predictor for clinical outcome. Our results show that the fraction of regurgitation better defines the clinical significance of MR than the absolute values of quantitative parameters. Therefore, the RF should be reported as part of the quantitative assessment of MR severity.

Arrhythmic mitral valve prolapse: beyond valve geometry, traction forces quantification

Abstract Introduction Arrhythmic Mitral Valve Prolapse (AMVP) constitutes a subgroup of Mitral Valve Prolapse (MVP) patients who, without necessarily having significant insufficiency, exhibit an increased risk of malignant ventricular arrhythmias (VA). Although this entity has recently gained significant attention in the scientific community, its pathophysiology and phenotypic characterization remain not completely elucidated. It has been postulated that leaflet displacement increases tension on the papillary muscles (PM), causing excessive superior traction. This may serve as the trigger for VA and, over time, lead to localized myocardial remodeling and subsequent fibrosis at the level of PM and left ventricle (LV) basal inferolateral wall, which is seen in this population. We believe we can identify and quantify this mechanism using transthoracic echocardiography (TTE). Therefore, we could define high-risk patterns for VA in this population before they occur. Purpose The aim of the study was to describe mitral valve (MV) geometry and quantify traction forces (TF) using TTE in patients with benign MVP and AMVP, and to compare these parameters between these two populations. Methods This retrospective observational study included 22 patients, 18 with benign MVP and 8 with AMVP. MV geometry and TF were measured using TTE. MVP was defined as the displacement of one or both leaflets ≥ 2 mm above the mitral annulus (MA) plane in parasternal long-axis view, and AMVP as MVP combined with frequent or complex VA. Patients with significant mitral regurgitation were excluded to eliminate its potential modifying effect on TF. Clinical variables were obtained from electronic medical records. LV parameters and MV geometry were measured by TTE, and TF were quantified as the variation in distance between the PM and MA from proto to mesosystole in apical 3 chamber view. Results Clinical characteristics and echocardiographic measurements are presented in the Table. The groups were comparable in terms of age, gender, LV dimension, function, and Global Longitudinal Strain (GLS). As expected, the AMVP group exhibited more symptoms, pathological ECG findings, and abnormal Holter results. In terms of MV geometry, the AMVP group had larger prolapsing area and height, with predominantly bileaflet involvement. Mitral annular disjunction (MAD) was also significantly more frequent in this group. Regarding TF quantification, the AMVP group showed greater PM-MA distance in protosystole and a higher variation in this distance between proto- and mesosystole compared to the benign MVP group. Conclusion These results support the hypothesis that AMVP patients exhibit significantly higher TF during systole. While larger clinical trials are needed to reach firm conclusions, this parameter could constitute a new measurable characteristic of this population, contributing to phenotypic characterization and early identification of AMVP, potentially before the occurrence of a fatal event.

Prediction of mortality by echocardiographic parameters: human vs. fully-automated AI-based analysis

Abstract Background The use of artificial intelligence (AI) for echocardiography analysis has been rapidly advancing and integrating into clinical practice. AI applications have demonstrated good accuracy in validation models compared to human experts. It is unclear how fully automated echocardiographic measures correlate with clinical outcomes, as compare to human readers. Purpose We aim to compare the performance of AI-based vs human expert-based analysis of echocardiographic measurements in prediction of mortality. Methods We retrospectively analyzed 889 consecutive hospitalized patients who underwent a clinically indicated transthoracic echocardiographic study. Each study was performed by experienced cardiac sonographers and reviewed by expert echocardiologists. All studies were also analyzed by a commercial, fully automated AI software (Us2.AI). For both human and AI measurements, we constructed multivariable models to predict 1-year all-cause mortality. Variables included in the models were selected based on their significance in univariate analysis. Cut-offs values were identified using a decision tree and the Chi-squared Automatic Interaction Detector (CHAID) algorithm. We used receiver operating characteristic (ROC) curves to determine which model provided stronger predictive power for mortality. Results Of the 889 patients, 731 (82%) patients (mean age 68±16, 46% Female) had sufficient echocardiographic data to be included in the analysis. One-year mortality was 13% (95 patients). Table 1 shows univariate analysis of human and AI measurements for 1-year all-cause mortality. 15 parameters automatically obtained by the AI system were found to be correlated with mortality, while 9 parameters from the human-based analysis were significant. In the multivariable regression model for 1-year mortality (Figure 1), the AI model showed superior predictive value (ROC area under the curve =0.758 vs. 0.709, P=0.041). Conclusion In this cohort of hospitalized patients, fully automated AI-based echocardiographic analysis was superior to human expert analysis in prediction of 1-year mortality. Univariate analysis for mortality Multivariable regression model

Artificial intelligence-assisted left ventricular global longitudinal strain assessment in patients with acute myocardial infarction: a sub-study of RESUS-AMI trial

Abstract Background Data on the use of global longitudinal strain (GLS) for assessing patients who had undergone primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) remains scarce. Purpose The aim of this sub-analysis of the RESUS AMI trial was to evaluate the feasibility and reproducibility of artificial intelligence (AI)-assisted echocardiographic assessments in STEMI patients after primary PCI and the correlation with the left ventricular ejection fraction (LVEF), volumes, and infarct size assessed with cardiac magnetic resonance (CMR) imaging. Methods Echocardiographic datasets were analysed with an AI-assisted software (CAAS Qardia 2.0) using fully automated and semi-automated (i.e. manual correction on the automated contours) methods to determine the LVEF, dimensions and GLS. CMR datasets were analysed with an off-line workstation (CAAS MRV 4.1) in a CMR core lab for the LVEF, dimensions and infarct size. Inter and intra-observer reproducibility of echocardiographic assessments were also assessed in 40 echocardiograms selected with completed views and sufficient acoustic window. Results In total 169 echocardiograms were analysed and the GLS was -11.7±3.0% (automated) and -12.2±3.0% (semi-automated) and showed moderately high correlation with the LVEF (r=-0.51 automated and -0.67 semi-automated, both p&amp;lt;0.0001). When compared with the cardiac measurements from 81 CMR recordings, the GLS showed moderately high correlation with the infarct size (r=0.58 automated and 0.64 semi-automated, both p&amp;lt;0.0001) and LVEF (r=-0.63 automated and -0.65 semi-automated, both p&amp;lt;0.0001). The inter-observer reproducibility was excellent in GLS from both the automated (ICC=0.94, bias=0.08, LoA=1.75) and semi-automated analysis (ICC=0.95, bias=-0.38, LoA=1.49); excellent in LVEF from the automated (ICC=0.98, bias=0, LoA=5.3) and moderate-high from the semi-automated (ICC=0.73, bias=3.6, LoA=10.43) groups. LV volumes had very good to excellent interobserver reproducibility. The interobserver reproducibility was excellent in all echocardiographic measures in both automated and semi-automated groups. Conclusion GLS derived from the AI-assisted software (either automated or semi-automated) appears to be an accurate marker of LV systolic function as it correlates well the infarct size and LVEF assessed with CMR and LVEF with echocardiography.

Myocardial work and extravalvular cardiac damage stages: hand-in-hand predictors of all-cause mortality in patients undergoing transcatheter aortic valve replacement

Abstract In patients with aortic stenosis (AS) evaluating left ventricular (LV) systolic function is challenging due to the influence of increased afterload on traditional measures. Myocardial work (MW) analysis, a novel echocardiographic method, adjusts myocardial deformation to instantaneous LV pressure, providing a more accurate reflection of LV contractile state. Notably, prolonged LV pressure overload induces significant backward effects beyond the LV; the classification of this extravalvular cardiac damage effectively represents the cardiopulmonary system's involvement in AS. Both MW analysis and cardiac damage staging may possess significant prognostic value in the clinically complex cohort of transcatheter aortic valve replacement (TAVR) candidates. Thus, our objective was to evaluate the prognostic value of MW analysis and cardiac damage staging in TAVR patients. We enrolled 314 patients (79±6 years, 40% female) prior to TAVR. Echocardiographic assessments were conducted one day before the procedure. LV ejection fraction (EF) was calculated, global longitudinal strain (GLS) was measured using speckle-tracking echocardiography. LV pressure was estimated from systolic blood pressure and transaortic mean gradient, and global constructive work (GCW) was quantified using dedicated software. Based on echocardiographic data, we determined the extent of cardiac damage associated with AS, categorizing patients into Stage 0 (no cardiac damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (pulmonary artery vasculature or tricuspid valve damage), or Stage 4 (right ventricular damage). The primary endpoint was all-cause mortality, reached by 69 patients during a median follow-up period of 25 months. Preprocedural EF was 47±13 %, GLS was -12.3±4.2 %, GCW was 2043±769 mmHg%. 14 (5%) patients were classified as Stage 0, 61 (20%) as Stage 1, 133 (43%) as Stage 2, 22 (7%) as Stage 3, and 74 (24%) as Stage 4. GCW showed a decline through AS Stages (from Stage 0-4: 2963±652 vs. 2154±621 vs. 2174±706 vs. 2044±827 vs. 1553±757 mmHg%; p&amp;lt;0.001). Using univariate Cox analysis GCW (HR 0.968 [95% CI 0.938-0.998] per 100 unit change; p=0.034) and AS Staging (HR 1.236 [95% CI 1.016-1.505]; p=0.034) were associated with all-cause mortality, while EF (HR 0.982 [95% CI 0.964-1.001]; p=NS) and GLS (HR 1.047 [95% CI 0.989-1.108]; p=NS) were not. In multivariate Cox regression models, both GCW (HR 0.958 [95% CI 0.923-0.994] per 100 unit change; p=0.022) and AS cardiac damage staging (HR 1.281 [95% CI 1.040-1.577]; p=0.020) were significant independent predictors of all-cause mortality. In TAVR patients, preoperative GCW values continuously decreased across all AS Stages. GCW and AS Staging showed strong association with all-cause mortality in our cohort, while EF and GLS did not. Furthermore, GCW and AS Staging had higher prognostic value than any other echocardiographic measure, highlighing their role in preprocedural assessment before TAVR.

Low myocardial work assessed by echocardiography is associated with prolonged ICU-Stay in CABG patients

Abstract Objectives The aim of this study was to investigate whether echocardiographic assessment of myocardial work is a predictor of outcome in patients undergoing operative revascularization. Background Global work index (GWI) is calculated by means of speckle tracking, blood pressure measurement at the moment of strain analysis, and a normalized reference curve. The prognostic value of GWI in patients who are scheduled for bypass surgery is unknown. Methods In this retrospective analysis, 193 patients scheduled for a bypass operation were tracked using echocardiographic strain measurement and calculation of the Global Longitudinal Strain (GLS), the GWI and ejection fraction concerning outcome parameters. The primary endpoint was the occurrence of intrahospital major cardiac events (MACE). As secondary endpoints, prolonged ICU stay (more than 24 hours), requirement for catecholamines (more than 12 hours) and duration of mechanical ventilation (mora than 12 hours) were defined as well as all-cause mortality within a year. Both GWI, EF, and Strain were examined for their validity with respect to the primary and secondary endpoints. Results The mean patient age was 63.41 years (SD 8.67). The median left ventricular ejection fraction was 53.78 % [IQR 48.30, 57.46] and the median global longitudinal strain -14.73 % [IQR-17.20, -11.87]. The median GWI was 1428.00mmHg% [IQR 1074.00, 1725.00]. Regarding the primary endpoint, no statistically significant differences were found between patients with a GWI of over 1000 mmHg% and those with a GWI of under 1000 mmHg% (p=0.281), which can be attributed to the low number of MACE events (n=13). For the secondary endpoints, there was no significant difference in terms of the duration of mechanical ventilation between patients with a GWI of under or over 1000 mmHg% (p= 0.879). However, there was a significantly higher risk for a longer stay in the ICU (OR 3.44, 95%CI [1.54, 8.33], p=0.004) among patients with a GWI of under 1000 mmHg%, and furthermore, a higher requirement for catecholamines was observed (p= 0.007). Conclusion GWI is associated with prolonged ICU Stay above 24 hours and requirement for catecholamines, but not for mace or ventilation time.

Effect of apical foreshortening and transducer angulation on strain measurements: a quantitative investigation

Abstract Background Two-dimensional echocardiographic strain measurements have limited reproducibility, hampering the ability to detect subtle changes in repeated examinations. This is partly related image acquisition, including apical foreshortening and suboptimal transducer rotation and/or tilt, resulting in non-standardized imaging planes. However, the impact of image acquisitions on measured global longitudinal strain (GLS) values has not been quantified in large studies due to the labor-intensive task of measuring apical foreshortening and characterizing the imaging plane. Recent advances in echocardiographic image analysis based on deep learning (DL) may shed new light on this problem by enabling measurements of apical foreshortening and estimation of transducer angulation without human intervention. Purpose To quantify the effect of apical foreshortening and transducer rotation/tilt on GLS values. Methods To isolate the effect of foreshortening and transducer rotation/tilt on GLS values, 1395 patients without cardiac pathology were included in the analysis. For each patient, GLS was measured in the three apical views (four chamber, two chamber, long-axis) using commercial software. The same recordings were automatically analyzed using DL to obtain indicators of apical foreshortening (apex displacement in the long axis and short axis directions) and of the transducer rotation and tilt relative to the heart. Correlations between strain values and the foreshortening/rotation/tilt indicators were calculated. When significant correlation was detected, a regression analysis was performed to quantify the absolute change in GLS that can be related to foreshortening and transducer rotation/tilt. The first and last 5% quantiles of each DL indicator were excluded from these analyses. Results For each view, GLS was significantly correlated (p&amp;lt;0.05) with at least one of the foreshortening or transducer angulation indicators (Fig. 1). The regression analyses suggested that apical foreshortening and suboptimal transducer rotation/tilt can cause GLS variations up to 1.3 percentage points, representing a relative change of 6.5%. Conclusions Apical foreshortening and transducer rotation/tilt quantified using automatic DL methods were related to GLS values in a large dataset. The magnitude of the relationship suggests that apical foreshortening and transducer rotation/tilt can limit the usefulness of GLS measurements, especially in the context of repeated examinations where detecting small relative changes is important. Overall, this retrospective analysis confirms the importance of minimizing apical foreshortening and of standardizing transducer angulation to reduce minimal detectable changes in GLS and improve its reproducibility.

Right ventricular stroke work index from echocardiography in patients with pulmonary arterial hypertension, the role in follow-up assessment

Abstract Background Right ventricular (RV) failure cause high mortality in patients with pulmonary arterial hypertension (PAH) (1,2,3,4). RV stroke work index (RVSWI) poses as a possible invasive determinant of outcome. Non-invasively measured RVSWI could be argued useful (5, 6, 7, 8, 9). Echocardiography-derived RVSWI (RVSWIECHO) encompassing either systolic (sPAP) or mean pulmonary arterial pressure (mPAP) is associated with invasive RVSWI (RVSWIRHC). The aim of this study is to evaluate how RVSWI by echocardiography or right heart catheterization (RHC) is altered following PAH-treatment and if RVSWI at baseline is an indicator of outcome in PAH. Methods Fifty-four consecutive patients with PAH (65 ± 13 years, 36 women) analyzed at baseline and at first follow-up visit (141 ± 79 days) were included in the study. Echocardiography and RHC were performed within a median of 0 day [IQR 0-1 days]. PAH-treatment was initiated after baseline examinations. RVSWIRHC was computed as (mPAP-mRAP)xSVIRHC (mRAP: mean right atrial pressure; SVI stroke volume indexed to body surface area). From echocardiography, tricuspid regurgitant (TR) maximum velocity and mean pressure gradient (PG) and SVI were assessed. RVSWIECHO was computed as RVSWIECHO-Max=TRmaxPGxSVIECHO and RVSWIECHO-Mean=TRmeanPGxSVIECHO. Results Invasive sPAP, mPAP and pulmonary vascular resistance (PVR) decreased from baseline to follow-up (sPAP: 76±18 vs 65±20 mmHg; mPAP: 47±11 vs 39±12 mmHg; PVR: 10.3 ±5 to 6.5±3.3 WU; p&amp;lt; 0.01 for all), and SVI increased (29±8 vs 37±10 ml/m2, p&amp;lt;0.01). RVSWIRHC and RVSWIECHOMax-Mean did not differ from baseline to follow-up (RVSWIRHC: 1132±352 vs 1208±467 mmHg*mL*m-2 (p=0.1); RVSWIECHO-Max: 1904±568 vs 1967±727 mmHg*mL*m-2 (p=0.5); RVSWIECHO-Mean: 1090±306 vs 1192±482 mmHg*mL*m-2 (p=0.1)). At long-term follow-up, 40 patients had died. None of the echocardiographic or invasive measures at baseline (including RVSWI) differed between survivors and non-survivors. In univariate Cox proportional hazard analysis, none of the RVSWI methods were associated with long-term mortality. However, age&amp;gt;65 years, six minutes’ walk distance test (6 MWT) &amp;lt;160 m, WHO class III-IV and indexed right atrium volume were associated. Adding these parameters as input in a model of multivariate analysis showed that echocardiography derived RVSWI (RVSWIECHO-Max (HR =1.001; CI 1-1.001; p=0.016); RVSWIECHO-Mean (HR =1.001; CI 1-1.002; p=0.006)) were independently associated with mortality. Conclusion None of the RVSWI methods differed from baseline to follow-up in patients with PAH, despite substantial improvement in conventional hemodynamic parameters. The baseline RVSWI methods were not associated with long-term mortality in univariate analysis. However, when adjusting for clinical variables in a multivariate analysis a significant association between echocardiography-derived RVSWI and mortality could be detected.

Clinical value of preoperative cardiac magnetic resonance imaging and echocardiography to identify post-operative left ventricular dysfunction in primary mitral regurgitation

Abstract Background Post-operative left ventricular (LV) dysfunction remains a common adverse consequence in patients with primary mitral regurgitation (MR) undergoing mitral valve (MV) surgery. Currently, cardiac magnetic resonance imaging (CMR) is a very useful imaging modality that complements echocardiography (Echo) in providing accurate grading of MR severity in these patients. Yet it remains unclear whether the consideration of CMR-assessed LV volumes and function would offer advantages over conventional echocardiographic LV measurements in identifying patients at risk of LV systolic dysfunction after MV surgery. Purpose We sought to compare the relationship between CMR- or Echo-assessed preoperative LV volumetric and function measurements and the occurrence of post-operative LV systolic dysfunction in patients with chronic significant primary MR undergoing MV surgery. Methods The study population consisted of 214 patients (median age: 59 years, 20% women) with chronic significant primary MR due to MV prolapse or flail who underwent echocardiography and CMR in 2 tertiary centers, between 2005 and 2022, before MV repair surgery. The endpoint was the occurrence of post-operative LV systolic dysfunction (defined as LV ejection fraction [EF] &amp;lt; 50%) at echocardiographic follow-up when available. ROC curves were used to evaluate relations between preoperative Echo or CMR characteristics and post-operative LV dysfunction. Side-by-side comparisons of AUCs were done using DeLong’s tests. Results At echocardiographic follow-up, 40 patients (19%) had post-operative LV dysfunction, with a median follow-up time of 8.6 months (interquartile range: 6.7 – 12.5 months) after MV surgery. Compared with those with normal LV function, patients with post-operative LV dysfunction exhibited higher absolute and indexed (ind) LV end-systolic diameters (ESD) and volumes (ESV) (all p&amp;lt;0.043, Figure 1). These patients also showed lower preoperative CMR-assessed LVEF (p=0.004), while Echo-LVEF did not show a significant relationship (p=0.071). Additionally, no relationship was found between MR quantitative parameters (regurgitant orifice area, volume, or fraction) and post-operative LV function (all p&amp;gt;0.247). The AUCs of the imaging preoperative characteristics tested (LVESD, indLVESD, Echo-indLVESV, CMR-indLVESV, Echo-LVEF, CMR-LVEF) numerically ranged from 0.59 (0.50-0.69), p=0.034 (Echo-LVEF) to 0.69 (0.60-0.77), p&amp;lt;0.001 (Echo-indLVESD, Figure 2). No significant differences were found in the side-by-side comparisons of the AUCs (all p&amp;gt;0.118). Conclusion In this series of patients with chronic significant primary MR who underwent MV surgery, conventional preoperative Echo and CMR LV measurements had similar diagnostic value in detecting post-operative LV systolic dysfunction. Our results indicate that both echocardiography and CMR are valuable imaging tools for identifying primary MR patients at risk of post-operative LV dysfunction. Figure 1 Figure 2

Cardiac systolic and diastolic function in relation to cardiovascular risk factor distribution: a comparison of strain-rate imaging in Russian and Norwegian populations

Abstract Background and Purpose Cardiovascular morbidity and mortality rates are high in Russia and it is likely that this reflects a similar impact on the general cardiac health of the population. The current study seeks to compare standard echocardiography and strain-based measurements between Russian and Norwegian populations, while also exploring their links to hemodynamic and risk factors. Methods This study included echocardiographic measurements of 1,192 participants from Russia, and 917 from the Study population, Norway. The sample included men and women aged 40–69 years. Normalcy, defined as the absence of hypertension or indicators of CVD, was observed in 840 individuals. We performed conventional echocardiography and analysed two-dimensional speckle-tracking longitudinal strains, including systolic, early-, and late-diastolic SR values. The study population was divided into four groups: normal, controlled hypertension, hypertensive blood pressure, and cardiac disease. Echocardiographic parameters were compared between the Russian and Norwegian populations, adjusted for age, sex, height, body mass index, blood pressure, heart rate (HR), atrial fibrillation (AF), smoking, pulmonary hypertension, and serum values for total, LDL (low density lipoprotein), and HDL (high density lipoprotein) cholesterol; triglycerides; creatinine; high-sensitivity C-reactive protein; and HbA1C. Results Russians showed a tendency towards lower longitudinal systolic functional parameters, which were most prominent in the normotensive group. However, these differences became insignificant after adjusting for parameters that influence pre- and after-loads. Russians also had a lower stroke volume, higher HR, higher left atrial volume, lower A, and higher E/A ratio, indicating a higher incidence of diastolic dysfunction in the Russian population that persisted after adjustments. Conclusion After adjusting for factors that influence cardiac function, there were no differences in systolic functional parameters between the Norwegian and Russian populations. However, differences in diastolic parameters, which persisted after adjusting for conventionally influential factors, indicated unexplained underlying causes of diastolic dysfunction in the Russian population. Figure 1 Table 1

Echocardiographic estimation of cardiovascular energy transfer in patients with heart failure: an explorative study

Abstract Background Heart failure (HF) is a complex and debilitating condition. The pathophysiology of HF is related to the dynamic interplay governing the energy transfer from the heart to the vascular bed. This energy transfer can be estimated by calculating the heart's external power, measured in watts, which is the product of flow and pressure divided by time. Although power measurements can potentially improve hemodynamic assessment in patients with heart failure, clinical estimation of cardiovascular energy transfer is rarely used due to cumbersome analyses and dependence on invasive measurements. We propose a novel method based on echocardiography and continuous non-invasive blood pressure measurement to estimate cardiovascular energy transfer. Aim To test whether non-invasive estimates of cardiovascular energy transfer can differentiate between HF patients with reduced and preserved left ventricular ejection fraction (LVEF). Methods We included patients hospitalized with decompensated HF not optimally treated in the study. All patients underwent an echocardiographic examination using a GE HealthCare Vivid E95 scanner. We used the biplane Simpson method to calculate LVEF and the pulsed wave Doppler velocity spectrum in the left ventricular outflow tract to estimate flow. Continuous non-invasive blood pressure measurements were obtained using a Finapres finger cuff device calibrated with the brachial blood pressure. We developed an application for tracing the velocity spectrum, synchronizing flow and pressure curves, and calculating the power curves as the product of continuous synchronized flow and pressure curves. The patients were categorized into two groups based on whether LVEF was &amp;lt; 40% or ≥ 40%. Results We observed that cardiovascular energy transfer, estimated as external power, differed between patients with LVEF &amp;lt;40% vs. ≥40%. The study cohort comprised twenty-eight patients (25% women), averaging 76 years (SD 11). Eighteen patients had LVEF &amp;lt;40%, with a mean LVEF of 27% (SD = 9%), mean velocity time index (VTI) 11.7 cm (SD = 2.94), and) and mean systolic blood pressure 116 mmHg (SD = 19). Ten patients had LVEF ≥40%, with a mean LVEF of 47% (SD = 6 %), VTI 16.5 cm (SD = 5.50), and mean systolic blood pressure 143 mmHg (SD = 20). External power was significantly different between patients with LVEF &amp;lt;40% vs. ≥40%, 0.81 W (SD = 0.21 W) vs. 1.43 W (SD = 0.41 W), respectively, p&amp;lt;0.0001 (Fig. 1). We observed a modest but significant correlation between LVEF and power (R = 0.28, P-value &amp;lt; 0.005). Conclusion Cardiovascular energy transfer, estimated non-invasively as external power, was significantly lower in acutely decompensated heart failure patients with LVEF &amp;lt;40% compared to those with LVEF ≥ 40%. More extensive studies should explore the possible value of estimating cardiovascular energy transfer in stratification and therapeutic decisions in patients with HF.

Epicardial adipose tissue thickness - a new predictive factor for coronary artery disease

Abstract Introduction The role of pericardial adipose tissue has been investigated in numerous studies in relation to the development of coronary artery disease (CAD) and other cardiac pathologies. Total pericardial fat (TPF) consists of epicardial adipose tissue (EAT), which is located between the myocardium and the visceral pericardium, and pericardial fat (PCF), which adheres to the parietal pericardium. The suspected mechanisms are complex and include the acceleration of inflammation and oxidative stress as well as proximity to the coronary arteries. Purpose The aim of the study was to investigate the existence of a correlation between the thickness of epicardial and pericardial adipose tissue and the presence of CAD, with the hope of using this marker in the future for risk stratification of cardiovascular disease. Methods This study enrolled 264 patients with a mean age of 59,9 +/- 10.6 years, 60,6% (160 pts) male, with cardiovascular risk factors who were investigated for suspected CAD. In all patients, the thickness of the TPF, EAT, and the PCF were measured echocardiographically during end-diastole, at the anterior atrioventricular groove. Intra- and interobserver variability was excellent (ICC 0.995-0.998 and ICC 0.992-0.995 for all three layers). Results Out of the total patients included, 54,2% (142 pts) had lesions on conventional angiography, of which 46% had hemodynamically significant lesions requiring revascularization. There were no statistically significant differences in the thickness of the three layers according to the presence of cardiovascular risk factors (diabetes mellitus, smoking, hypertension) and there was no correlation with body mass index. There were statistically significant differences in the dimensions of the pericardial adipose tissue layers between the group of patients with CAD and the group of patients without CAD (EAT 7,1 +/-2,34 vs 5,07+/-2,36 mm, PCF 9.3+/-3,01 vs 7,2+/-2,9 mm and TPF 16,7+/-3,8 vs 12.59+/-4,3 mm, p=0.001 for all cases). There were no statistically significant differences between patients who had one, two, or all three coronary arteries affected (p=0.5). There is a significant correlation between EAT and TPF (r 0.81), PCF and TPF (r 0.83), but no significant correlation between the two substrates (r 0.44). Women without CAD had a lower epicardial layer thickness than men without CAD (4,8+/-0,26 vs 5,4+/-0,29,p &amp;lt;0,001), but this difference did not exist in those with CAD (6.9+/-0.47 vs 7.2+/-0.24). Conclusions The study shows that echocardiographic measurement of the thickness of pericardial adipose tissue layers is a feasible method, easy to perform with good intra- and interobserver reproducibility. The data presented suggest that the thickness of the pericardial adipose tissue layers (EAT and TPF) may represent an independent risk factor for CAD and could be included in the pre-test risk assessment of patients with suspected CAD.

Prediction of tricuspid regurgitation regression after mitral valve transcatheter edge-to-edge repair using three-dimensional transesophageal echocardiography

Abstract Aims We aimed to identify three-dimensional echocardiographic predictors of tricuspid regurgitation (TR) regression in patients with functional TR of moderate or greater severity undergoing mitral valve transcatheter edge-to-edge repair to optimize patient selection and improve clinical outcomes. Methods and Results This retrospective study analyzed 61 patients (mean age 81.3±7.6 years; 55.7% males) who underwent mitral valve transcatheter edge-to-edge repair. Two-dimensional transthoracic echocardiography was performed pre- and 1-month post-procedurally, while three-dimensional transesophageal echocardiography was performed pre-procedurally. We collected data on clinical variables, medications, and detailed echocardiographic measurements to evaluate procedural outcomes. TR severity was semi-quantitatively assessed and categorized. At the 1-month follow-up, TR severity had regressed in 43% of patients. A lower prevalence of atrial fibrillation, smaller left atrial volume index, and smaller right atrial area were significantly associated with TR regression. Multivariate analysis revealed the tricuspid valve annulus perimeter, area, and area change as significant predictors of post-procedure TR regression; tricuspid valve annulus perimeter was the strongest predictor among the three indicators (area under the receiver operating characteristic curve, 0.84 [95% confidence interval: 0.75–0.94], p&amp;lt;0.001). Receiver operating characteristic curve analysis indicated that tricuspid valve annulus perimeter cut-off of ≤13.75 cm was the best predictor of post-procedure TR regression. Additionally, tricuspid valve annulus area ≤13.55 cm² and annulus area change ≥17.5% were predictors of post-procedure TR regression. Conclusion In patients with relatively severe mitral regurgitation with a non-dilated tricuspid annulus and significant change in tricuspid valve annulus area, mitral valve transcatheter edge-to-edge repair may lead to TR regression.

Evaluation of the presence and extension valvular-related cardiac damage in patients with moderate aortic stenosis and its impact on outcomes

Abstract Introduction and objective Echocardiographic measurements form the basis for diagnosing and determining the indication for therapy in aortic stenosis (AS). These measurements may vary depending on different patient-related and operator-related conditions. Recently, staging cardiac damage has emerged as a prognostic tool in asymptomatic and moderate to severe AS. We aim to evaluate the presence and severity of cardiac damage (1,2), and its impact on outcomes, in patients with a first diagnosis of moderate and severe AS. Methods A total of 119 patients undergoing transcatheter aortic valve replacement (TAVR) from November 2019 to January 2021 were included in a single-center retrospective registry. In each patient, the first echocardiogram establishing the diagnosis of moderate and severe AS was analysed. Results 119 patients with a mean age of 82.8±5.33 years (51% men) were included. At the first echo study with the diagnosis of moderate AS, mean pressure gradient was 23±9 mmHg, maximum pressure gradient was 42±15 mmHg, and mean aortic valve area was 1.13±0.41 cm2 (0.64±0.23 cm2/m2). Regarding cardiac damage, mean left ventricular ejection fraction was 65.4±10.4%, mean longitudinal global strain was -18.5±5.4%, and mean left atrial volume index was 41.6±31.2 mL/m2. 16% of patients have significant mitral regurgitation, and 10% right ventricular dysfunction. The mean progression time between moderate and severe diagnoses was 36 (2.4-175.2) months. Figure 1 shows the distribution of patients in different staging classification systems (1,2) at the time of diagnosis of moderate and severe AS. According to one of these staging classifications (1), 75.7% of patients had left-sided cardiac damage (Stages 1 and 2) and 16.8% had right-sided damage (Stages 3 and 4), without differences compared to the same patients when the stenosis became severe (p=0.194). On the contrary, following the most recent second classification (2), 63% had no significant cardiac damage (Stage 0), 31.1% of patients had left-sided cardiac damage (Stages 1 and 2) and 5.9% had right-sided damage (Stage 3), and this system showed better ability to discriminate between moderate and severe AS related-damage (p=0.002). The area under the ROC curve for one-year mortality after TAVR for the 2 staging systems applied at the moment of diagnosis of moderate and severe AS is presented in Figure 2. When used in moderate AS, it showed fair discrimination. However, the best model for predicting one-year mortality among those used, is the one used in the second classification (2) when the stenosis became severe. Conclusions AS-related cardiac damage may be present in early stages of AS and may help to guide the timing of intervention in selected patients. Staging classification of cardiac damage AUROC curve for one-year mortality

Echocardiographic nomograms of heart chambers and great arteries in peruvian children living at high altitude according to sex

Abstract Background Reference values in pediatric echocardiography are crucial for clinical decision making. The availability of nomograms may support interpretation of the echocardiographic findings and clinical diagnosis. Cardiac chamber dimensions vary according to body size, age, sex, and to some extent, geographic background in children. Purpose The aim of this study was to establish two-dimensional and M-mode echocardiographic reference values for cardiac chambers, outflow tracts and great vessels for school children living at high altitude, differentiated between male and female. Methods This is a post-hoc analysis from a cluster randomized cross-sectional survey of rheumatic heart disease in school children in Arequipa, Peru. Children with normal echocardiographic screening were included for this sub-study. The echocardiograms were acquired with a portable machine and the images were analyzed centrally with a standardized methodology. Body surface area (BSA) was used as an independent variable to predict the mean values of echocardiographic measurements for both male and female groups. Reference values are presented with z-scores and nomograms based on the sex. Results A total of 985 students from ages 5-16 years were included. The Haycock formula provided the best fit and was used when presenting data as predicted values for a given BSA. The z-score and nomograms for all essential dimensional measures of cardiac chambers and great vessel, as well as functional surrogates are presented based on sex. Left ventricular chamber and mass are presented in Figure 1 and right ventricular dimensions are presented in Figure 2. Conclusions Normal reference values and nomograms of cardiac chamber, outflow tracts and great arteries in healthy school children living at high altitude based on sex were reported. These data partly cover a gap in existing pediatric echocardiographic nomograms. Left ventricular chamber and mass Right ventricular dimensions