Four-chamber View Research Articles

Automatic Segmentation and Assessment of Valvular Regurgitations with Color Doppler Echocardiography Images: A VABC-UNet-Based Framework.

This study investigated the automatic segmentation and classification of mitral regurgitation (MR) and tricuspid regurgitation (TR) using a deep learning-based method, aiming to improve the efficiency and accuracy of diagnosis of valvular regurgitations. A VABC-UNet model was proposed consisting of VGG16 encoder, U-Net decoder, batch normalization, attention block and deepened convolution layer based on the U-Net backbone. Then, a VABC-UNet-based assessment framework was established for automatic segmentation, classification, and evaluation of valvular regurgitations. A total of 315 color Doppler echocardiography images of MR and/or TR in an apical four-chamber view were collected, including 35 images in the test dataset and 280 images in the training dataset. In comparison with the classic U-Net and VGG16-UNet models, the segmentation performance of the VABC-UNet model was evaluated via four metrics: Dice, Jaccard, Precision, and Recall. According to the features of regurgitation jet and atrium, the regurgitation could automatically be classified into MR or TR, and evaluated to mild, moderate, moderate-severe, or severe grade by the framework. The results show that the VABC-UNet model has a superior performance in the segmentation of valvular regurgitation jets and atria to the other two models and consequently a higher accuracy of classification and evaluation. There were fewer pseudo- and over-segmentations by the VABC-UNet model and the values of the metrics significantly improved (p < 0.05). The proposed VABC-UNet-based framework achieves automatic segmentation, classification, and evaluation of MR and TR, having potential to assist radiologists in clinical decision making of the regurgitations in valvular heart diseases.

Epicardial adipose tissue is associated with an increased risk of mortality and hospitalizations in patients with heart failure with preserved ejection fraction

Abstract Background Accumulating evidence suggests that epicardial adipose tissue (EAT) plays a critical role in heart failure (HF). Previous studies raised the possibility of an association with mortality and hospitalizations, but data in preserved ejection fraction (HFpEF) is sparse. Purpose To investigate the association of epicardial fat measured by cardiac magnetic resonance imaging (CMR) with the combined end point of heart failure hospitalizations and cardiovascular death in patients with heart failure with preserved ejection fraction Methods In this secondary analysis of a prospective cohort study recruiting participants with HFpEF between July 2012 and March 2018 at a tertiary care centre. Patients with cardiac amyloidosis were excluded. The combined primary endpoint of this analysis consists of heart failure hospitalizations and cardiovascular mortality. The statistical analysis plan consisted of a Cox proportional hazard regression adjusted for multiple potential confounders. Adjustments were predefined and selected by their clinical relevance. EAT volume was measured using a modified Simpson rule, EAT area was measured in the four-chamber view. EAT was defined from visceral (immediately adhering the myocardium) to the parietal layer of the pericardium. Epi-pericardial tissue was excluded. We used dark blood steady-state free precision (SSFP) at end-diastole. If unavailable we used bright blood SSFP or true fast imaging with steady-state free precession. Results We studied 206 patients (69% women, mean age 71±9 years, median N-terminal prohormone of brain natriuretic peptide [NT-proBNP]: 1090 IQR 420 – 1997pg/mL). During mean follow-up of 78±35 months, 78 patients (37%) died of a cardiovascular cause. In multivariate analysis adjusting for age, gender, atrial fibrillation, left-ventricular ejection fraction (EF), right ventricular (RV) end-diastolic volume index, RVEF and NT-proBNP, EAT was significantly associated with a higher risk of the composite outcome (HR 1.07 [95% CI 1.02-1.12], P = 0.007). Additional adjustments for hepatic-, renal- and pulmonary function as well as metabolic biomarkers did not materially change the results. There was no statistically significant association with pulmonary pressures on right heart catheterization. Conclusions EAT accumulation is associated with increased risk for mortality and hospitalizations in patients with HF with preserved ejection fraction. This finding supports the rational for future interventional studies of EAT in HFpEF. Conclusions EAT accumulation is associated with increased risk for mortality and hospitalizations in patients with HF with preserved ejection fraction. This finding supports the rational for future interventional studies of EAT in HFpEF.

Right atrial strain predicts collagen mRNA levels in human right atrium

Abstract Background Structural remodelling, which includes increased fibrosis and collagen production, is a hallmark of atrial cardiomyopathy. Echocardiographic strain measurements allow detailed assessment of atrial function. We investigated the association between right atrial (RA) strain and collagen mRNA levels in human RA. Methods RA biopsies were collected from 21 patients undergoing elective coronary artery bypass grafting in the prospective observational study CONSIDER-AF. Tissue mRNA levels of collagen type I (Col1A) and of collagen type III (Col3A) were quantified using real-time qPCR on ViiA 7 real-time PCR system. Echocardiographic RA strain (reservoir, conduit, and booster function) was measured in the four-chamber view using the designated software Philips QLAB. We performed uni- and multivariable linear regression analysis to elucidate the relationship between RA strain and collagen mRNA levels. Results There was a strong correlation between RA reservoir strain and Col1A mRNA levels (p=0.0152, r²=0.2608, Fig A) and Col3A mRNA levels (p=0.0058, r²=0.3374, Fig B) as well as between RA conduit strain and Col1A mRNA levels (p=0.0301, r²=0.2141, Fig C) and Col3A mRNA levels (p=0.0232, r²=0.2430, Fig D). However, there was no correlation between RA booster function and Col1A levels (p=0.5572, Fig E) or Col3A levels (p=0.3426, Fig F). Multivariate regression analysis revealed that RA conduit and RA reservoir function are predictors for Col1A and Col3A mRNA levels independent from clinical covariates (age, sex, body-mass index, systolic blood pressure). Discussion Our findings show that RA strain measurements are associated with RA collagen mRNA levels in humans and therefore highlight the potential of strain analysis to identify structural remodelling in atrial cardiomyopathy.FigureTable

Association of epicardial adipose tissue on magnetic resonance imaging with cardiovascular outcomes: Quality over quantity?

Abstract Background Quantity of epicardial adipose tissue (EAT) has been associated with poor cardiovascular outcomes. As suggested by computed tomography (CT) studies the quality of EAT may be of incremental prognostic value. Cardiac magnetic resonance (CMR) is the gold-standard for tissue characterization, however, has never been applied for EAT quality assessment. Objectives To investigate EAT quality measured on CMR T1 mapping as predictor of outcome in an all-comer cohort. Methods We measured EAT area (EATA) and T1 time (EAT-T1) in a four-chamber views (Figure 1) and tested for association with clinical, demographic, and laboratory parameters using linear regression models. We used Cox-regression analyses to test the association between EATA and EAT-T1 with a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and all-cause death. Results A total of 966 participants were included (47.2% female, mean age: 58.4years). Mean EATA was 7.3cm2 and mean EAT-T1 was 268ms. On linear regression EAT-T1 was not associated with markers obesity, dyslipidemia or co-morbidities such as diabetes (p&amp;gt;0.05 for all). During a follow-up of 57.7 months, a total of 280 (29.0%) events occurred. EAT-T1 was independently associated (adj. HR: 1.003, 95%-CI: 1.000 – 1.005, p=0.029, Figure 2) with the composite endpoint when adjusted for established clinical risk factors including age, sex, natriuretic peptide levels, left and right ventricular function, arterial hypertension, body mass index, and coronary artery disease. Conclusion In an all-comer CMR cohort, EAT quality, as measured on CMR T1-times, but not EAT quantity is independently associated with a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and all-cause death.Figure 1.Regions of interestFigure 2.Kaplan Meier Curves

Prognostic influence of left atrial strain in heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy

Abstract Background Heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms is class I indication for cardiac resynchronization therapy (CRT), whereas it is still controversy to CRT response in HF with QRS width 120-149ms or non-LBBB as intermediate ECG criteria in routine echocardiography. Left atrial (LA) adverse remodeling is a prognostic marker in patients with heart failure. Nevertheless, the prognostic significance of LA strain (LAS) imaging in HF patients with intermediate ECG criteria is not well understood. Purpose The objective of this study was to determine the prognostic value of LA deformation analysis in patients undergoing CRT implantation who met the intermediate ECG criteria. Methods We studied 94 patients who were defined routine CRT indication by the clinical guidelines. LAS was calculated as the average strain using apical two- and four-chamber views. The predefined endpoint was death, hospitalization due to worsening HF for 5 years after CRT implantation. Results Of the 94 patients, LAS is feasible in 76 patients (81%) with aged 69 ± 11 years, 30±8% of LV ejection fraction. 46 patients (61%) fulfilled intermediate ECG criteria. The predefined endpoint occurred in 43 patients (57%). The median LAS was 15%. LAS below 15% were associated with a high probability of unfavorable outcomes over 5 years (Log-rank, p = 0.002). After adjusting for left ventricular ejection fraction, LAS remained significantly associated with poor outcomes (hazard ratio 0.92, 95% confidence interval 0.87-0.97, p&amp;lt;0.001). There is no difference in the probability of poor outcomes between LBBB with QRS width ≥150ms and intermediate ECG criteria. Patients with intermediate ECG criteria and LAS &amp;lt;15% had worse outcome than in those with LBBB with QRS width ≥150ms and in those with intermediate ECG criteria patients with LAS ≥15% (Log-rank: p = 0.046, p = 0.029, respectively). Conclusion Baseline LA functional deterioration by deformation analysis was significantly associated with poor outcome after CRT implantation regardless of the ECG criteria for CRT indication and has promise for clinical utility.

Left atrial strain and long-term risk of atrial fibrillation in hypertrophic cardiomyopathy

Abstract Background The prevalence of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is higher than in the general population, and it is associated with an increased risk of adverse outcomes, such as stroke, heart failure, and mortality. The left atrium (LA) plays an important role in maintaining normal cardiac function, and alterations in its structure and function can contribute to the development of AF. LA strain, a surrogate of LA remodeling, has been suggested a predictor of future AF. Purpose The aim of this study was to explore risk factors of new onset AF highlighting LA strain in patients with HCM. Methods Among a prospective cohort of 865 HCM patients collected at two large tertiary centers, 696 with adequate echocardiographic images to measure LA strain without a history of AF were included in the analysis. LA strain was measured on apical four-chamber view at initial evaluation using vendor-independent speckle-tracking software. The primary endpoint was new onset AF during 10 years after initial evaluation. Results The median age was 55.0 years and 74.3% were male. A median value of LA reservoir strain (LARS) was 26.2 % [interquartile range 20.4, 33.3]. Among the 696 patients, 66 had new onset AF 10 years, with a 10-year incidence of 15.8%. The unadjusted risk factors for new onset AF were previous stroke, non-apical HCM, family history of HCM, non-sustained ventricular tachycardia, obstructive HCM, extensive late gadolinium enhancement, larger LA diameter, larger LA volume, and lower LARS. LARS remained an independent predictor of new onset AF in multivariable analysis. The best cut-off value of LARS was 17.9% (hazard ratio 4.00, 95% confidence interval 2.44–6.55, p&amp;lt;0.001). Compared with LARS ≥17.9%, LARS &amp;lt;17.9% was significantly associated with a higher incidence of new onset AF, irrespective of presence of clinical risk factors (Figure 1) and LA enlargement (Figure 2). Conclusions In patients with HCM, low LA strain is an independent predictor of new onset AF.

Veterinary echocardiographers' preferences for left atrial size assessment in cats: the BENEFIT project

Introduction/objectivesVeterinary echocardiographers' preferences for left atrial (LA) size assessment in cats have not been systematically investigated. The primary aim of this prospective exploratory study was to investigate echocardiographers' preferences concerning LA size assessment in cats. A secondary aim was to investigate echocardiographers' preferences for assessing LA size in subgroups based on geographic, demographic, and professional profiles. Animals, materials, and methodsAn online survey instrument was designed, verified, and distributed globally to veterinary echocardiographers. ResultsA total of 655 veterinary echocardiographers from six continents and 54 countries, working in specialty practice (56%) and in general practice (38%), provided data. Linear two-dimensional (2D) technique was favored by most echocardiographers (n = 612) for LA size assessment. Most commonly, respondents combined linear 2D with subjective assessment (n = 227), while 209 used linear 2D-based methods alone. Most echocardiographers using linear 2D-based methods preferred the right parasternal short-axis view and to index the LA to the aorta (Ao). Approximately 10% of the respondents obtained LA dimensions from a right parasternal long-axis four-chamber view. Approximately one-third of echocardiographers that made linear measurements from 2D echocardiograms shared the same preferences regarding cat position, acquisition view, indexing method and time point identification for the LA measurement. The responses were comparably homogeneous across geographic location, level of training, years performing echocardiography, and type of practice. Discussion/conclusionMost veterinary echocardiographers assessed LA size in cats using linear 2D echocardiography from a right parasternal short-axis view, and indexed LA to Ao. Respondents' preferences were similar over geographic, demographic, and professional backgrounds.

Standardized longitudinal strain curves stratified by age and sex in healthy individuals: The Copenhagen City Heart Study

Abstract Introduction Speckle-tracking echocardiography has gained widespread use, and strain parameters such as global longitudinal strain (GLS) and strain rates are strongly associated with risk of heart failure and cardiovascular death. Such strain measures, however, only represent limited features of the complete longitudinal strain (LS) curve. Thus, interpretation of entire curves might provide additional insight. Purpose To establish normal standardized LS curves over an entire heart cycle for healthy subjects stratified by age and sex. Furthermore, to assess how these curves vary with age and to compare this with conventional strain measures. Methods The study population consisted of 1790 healthy subjects free of cardiovascular disease and risk factors including diabetes mellitus and hypertension at baseline. Subjects were stratified by sex and further by age in groups as defined in the SCORE risk chart. Subjects underwent echocardiography, and LS curves from the apical four-chamber view were derived and standardized in length using linear interpolation. Terms to describe qualitative findings in the standardized strain curves were established (Figure 1). Early diastolic strain (EDS) was defined as the difference in strain from peak LS to maximal curvature after early diastolic filling, while late diastolic strain (LDS) was defined as the difference in strain from the plateau phase in late passive diastole to maximal curvature in active diastole. Conventional strain measures included GLS, systolic strain rate (SRS), early diastolic strain rate (SRE), and late diastolic strain rates (SRA). The association between these and age group were investigated using univariable linear regression for each sex. Results In the study population, 1101 (61.5%) subjects were female. The standardized strain curves (Figure 2) showed that aging primarily manifested in the diastolic part of the strain curve. Decreasing EDS was associated with increasing age group, while the opposite was true for LDS. In linear regression, both SRE (female: beta=-0.13; p&amp;lt;0.001, male: beta=-0.1; p&amp;lt;0.001) and SRA (female: beta=0.09; p&amp;lt;0.001, male: beta=0.09; p&amp;lt;0.001) were associated with age group for both sexes. Peak LS did not change notably with age, and in linear regression, GLS and SRS were only significantly associated with age for women (GLS: beta=0.12; p&amp;lt;0.001, SRS: beta=0.01; p&amp;lt;0.001). Conclusion We derived normal standardized LS curves for healthy individuals stratified by age and sex, which can serve as normal values in future studies. In addition, these showed that age was primarily associated with changes in the diastolic part of the strain curve in both sexes, which was consistent with conventional strain measures.Figure 1:Overview of termsFigure 2Standardized longitudinal strai

Abstract 13679: Personalized Guidance of Edge-to-Edge Transcatheter Tricuspid Valve Repair

Introduction: Transcatheter edge-to-edge tricuspid valve repair (T-TEER) for tricuspid regurgitation (TR) is always guided by TEE. Hypothesis: Safety and efficacy of T-TEER can be increased by multimodality imaging (MMI) guidance. Methods: From December 2020 to January 2022, we performed T-TEER in 40 inoperable patients. All patients received TTE, TEE and cardiac CT screening, and were assigned to a MMI (n=17) guidance group, provided good TTE acoustic window, or otherwise classical TEE (n=23). Multimodality imaging employed the 4 right-sided chamber views. Accordingly, the 1-chamber view was obtained in the transgastric short-axis view on TEE, but also from a modified subcostal TTE short axis. The 2-chamber view was visualized from a low-esophageal position, or from a parasternal long axis view of the right ventricle. The 3-chamber view was seen on mid-esophageal TEE 50-100°, but also in the parasternal short axis view. Finally, the 4-chamber view was obtained on mid-esophageal 0-30°, or the classical four-chamber TTE view. CT derived fluoroscopic angulations of these views allowed interventionalists and imaging specialists to speak a common language. Results: Device success was achieved in all patients, with 1.5±0.6 implanted clips / patient in the MMI vs 1.5±0.5 in the TEE group (p=0.851). Device times were 66.1±35.1 vs 58.7±27.5 minutes (p=0.459). TR reduction was successful in 94% vs 95% of patients, p=1.000. Two- or more grade TR improvement occurred in 65% vs 52% of cases. There were no device associated complications but 3 TEE-related gastro-esophageal bleedings occurred in the 2 nd group. By 12 months, 4 vs 8 patients (p=0.504) were readmitted for acute heart failure, and 2 vs 4 (p=0.686) died. NYHA class decreased by one grade in all survivals. However, Kansas City Cardiomyopathy Questionnaire score and 6-minute walk distance significantly increased in each respective group, more with MMI ( Δ 29±21.4 vs 22±13.6 points, p=0.227; Δ 101±100.4 vs 85±64 meters, p=0.121). Conclusions: A patient-tailored MMI approach to T-TEER guidance, by using TTE in patients with good acoustic window and cardiac CT for fluoroscopic determination of the 4 right-sided chamber views, is feasible and improves safety, procedural success and, in turn, clinical outcomes.

Improving the Quality of Fetal Heart Ultrasound Imaging with Multihead Enhanced Self-Attention and Contrastive Learning.

Fetal congenital heart disease (FCHD) is a common, serious birth defect affecting ∼1% of newborns annually. Fetal echocardiography is the most effective and important technique for prenatal FCHD diagnosis. The prerequisites for accurate ultrasound FCHD diagnosis are accurate view recognition and high-quality diagnostic view extraction. However, these manual clinical procedures have drawbacks such as, varying technical capabilities and inefficiency. Therefore, the automatic identification of high-quality multiview fetal heart scan images is highly desirable to improve prenatal diagnosis efficiency and accuracy of FCHD. Here, we present a framework for multiview fetal heart ultrasound image recognition and quality assessment that comprises two parts: a multiview classification and localization network (MCLN) and an improved contrastive learning network (ICLN). In the MCLN, a multihead enhanced self-attention mechanism is applied to construct the classification network and identify six accurate and interpretable views of the fetal heart. In the ICLN, anatomical structure standardization and image clarity are considered. With contrastive learning, the absolute loss, feature relative loss and predicted value relative loss are combined to achieve favorable quality assessment results. Experiments show that the MCLN outperforms other state-of-the-art networks by 1.52-13.61% when determining the F1 score in six standard view recognition tasks, and the ICLN is comparable to the performance of expert cardiologists in the quality assessment of fetal heart ultrasound images, reaching 97% on a test set within 2 points for the four-chamber view task. Thus, our architecture offers great potential in helping cardiologists improve quality control for fetal echocardiographic images in clinical practice.

Right ventricular free wall and four-chamber longitudinal strain in relation to incident heart failure in the general population.

Right ventricular free wall (RVFWLS) and four-chamber longitudinal strain (RV4CLS) are associated with adverse events in various patient populations including patients with heart failure (HF). We sought to investigate the prognostic value of RVFWLS and RV4CLS for the development of incident HF in participants from the general population. Participants from the 5th Copenhagen City Heart Study (2011-2015) without known chronic ischaemic heart disease or HF at baseline were included. RVFWLS and RV4CLS were obtained using two-dimensional speckle-tracking echocardiography from the right ventricular (RV)-focused apical four-chamber view. The primary endpoint was incident HF. Among 2740 participants (mean age 54 ± 17 years, 42% male), 43 (1.6%) developed HF during a median follow-up of 5.5 years (IQR 4.5-6.3). Both RVFWLS and RV4CLS were associated with an increased risk of incident HF during follow-up independent of age, sex, hypertension, diabetes, body mass index and tricuspid annular plane systolic excursion (TAPSE), (HR 1.06, 95%CI 1.00-1.11, P = 0.034, per 1% absolute decrease and HR 1.14, 95%CI 1.05-1.23, P = 0.001, per 1% absolute decrease, respectively). Left ventricular ejection fraction (LVEF) modified the association between RV4CLS and incident HF (P for interaction = 0.016) such that RV4CLS was only of prognostic importance among those with LVEF < 55% (HR 1.21, 95%CI 1.11-1.33, P < 0.001 vs. HR 0.94, 95%CI 0.80-1.10, P = 0.43 in patients with LVEF ≥ 55%). In participants from the general population, both RVFWLS and RV4CLS were associated with a greater risk of incident HF independent of important baseline characteristics and TAPSE, and LVEF modified the relationship between RV4CLS and incident HF.

Incidental Diagnosis of Left Pneumothorax Using a New Variant of the Lung Point Sign During Cardiac Ultrasound

BackgroundPneumothorax is a common issue in the intensive care unit and emergency department, often diagnosed using lung ultrasound. The absence of lung sliding and the presence of the lung point sign are characteristic findings for pneumothorax. We describe a case of left pneumothorax diagnosed incidentally while performing a cardiac ultrasound through a new variant of the lung point sign. Case ReportA 60-year-old patient with a medical history of diabetes, stroke, and right colon cancer underwent urgent surgical treatment for intestinal sub-occlusion. In the intensive care unit, the patient required mechanical ventilation due to shock unresponsive to fluid administration, and hemodynamic monitoring was performed using echocardiography. During systole in an apical four-chamber view, the abrupt vanishing of the heart was observed. When evaluating the tricuspid annular plane systolic excursion (TAPSE) using M-mode, the interposition of the stratosphere sign during mid-systole prevented the visualization of the TAPSE peak. Lung ultrasound revealed the absence of lung sliding and the presence of the lung point sign on the left side of the thorax, confirming the diagnosis of pneumothorax. A chest x-ray study further confirmed the diagnosis, and urgent drainage was performed. The patient showed improvement in hemodynamic and respiratory conditions and was successfully weaned from mechanical ventilation, and eventually discharged home. Why Should an Emergency Physician Be Aware of This?By incorporating the lung ultrasound findings, including this new variant of the lung point sign, into their diagnostic approach to pneumothorax, emergency physicians can promptly initiate appropriate intervention, such as chest tube insertion, leading to improved patient outcomes.

RETRACTED ARTICLE: Assessment of fetal intraventricular diastolic fluid dynamics using ultrasound vector flow mapping

ObjectiveThe purpose of this study was to investigate the feasibility of visualizing and quantifying the normal pattern of vortex formation in the left ventricle (LV) and right ventricle (RV) of the fetal heart during diastole using vector flow mapping (VFM).MethodsA total of 36 healthy fetuses in the second trimester (mean gestational age: 23 weeks, 2 days; range: 22–24 weeks) were enrolled in the study. Color Doppler signals were recorded in the four-chamber view to observe the phase of the diastolic vortices in the LV and RV. The vortex area and circulation were measured, and parameters such as intraventricular pressure difference (IVPD), intraventricular pressure gradient (IVPG), and average energy loss (EL_AVG) were evaluated at different diastolic phases, including isovolumic relaxation (D1), early diastole (D2), and late diastole (D3).ResultsHealthy second-trimester fetal vortex formations were observed in both the LV and RV at the end of diastole, with the vortices rotating in a clockwise direction towards the outflow tract. There were no significant differences in vortex area and circulation between the two ventricles (p > 0.05). However, significant differences were found in IVPD, IVPG, and EL_AVG among the diastolic phases (D1, D2, and D3) (p < 0.05). Trends in IVPD, IVPG, and EL_AVG during diastole (D1-D2-D3) revealed increasing IVPD and EL_AVG values, as well as decreasing IVPG values. Furthermore, during D3, the RV exhibited significantly higher IVPD, IVPG, and EL_AVG compared to the LV (p > 0.05).ConclusionVFM is a valuable technique for analyzing the formation of vortices in the left and right ventricles during fetal diastole. The application of VFM technology has the potential to enhance the assessment of fetal cardiac parameters.

Prenatal diagnosis of hypoplastic left heart syndrome on ultrasound using artificial intelligence: How does performance compare to a current screening programme?

Artificial intelligence (AI) has the potential to improve prenatal detection of congenital heart disease. We analysed the performance of the current national screening programme in detecting hypoplastic left heart syndrome (HLHS) to compare with our own AI model. Current screening programme performance was calculated from local and national sources. AI models were trained using four-chamber ultrasound views of the fetal heart, using a ResNet classifier. Estimated current fetal screening programme sensitivity and specificity for HLHS were 94.3% and 99.985%, respectively. Depending on calibration, AI models to detect HLHS were either highly sensitive (sensitivity 100%, specificity 94.0%) or highly specific (sensitivity 93.3%, specificity 100%). Our analysis suggests that our highly sensitive model would generate 45,134 screen positive results for a gain of 14 additional HLHS cases. Our highly specific model would be associated with two fewer detected HLHS cases, and 118 fewer false positives. If used independently, our AI model performance is slightly worse than the performance level of the current screening programme in detecting HLHS, and this performance is likely to deteriorate further when used prospectively. This demonstrates that collaboration between humans and AI will be key for effective future clinical use.

Three-dimensional analysis of the tricuspid annular geometry in healthy subjects and in patients with different grades of functional tricuspid regurgitation

BackgroundAccurate sizing of the tricuspid valve annulus is essential for determining the optimal timing of tricuspid valve (TV) intervention. Two-dimensional (2D) echocardiography has limitations for comprehensive TV analysis. Three-dimensional (3D) imaging of the valve provides a better understanding of its spatial anatomy and enables more accurate measurements of TV structures.ObjectivesThe study aimed to analyze tricuspid annulus (TA) parameters in normal heart and in different grades of functional tricuspid regurgitation (TR); to compare TA measurements obtained by 2D and 3D echocardiography.MethodsOne hundred fifty-five patients (median age 65 years, 57% women) with normal TV and different functional TR grades underwent 2D and 3D transthoracic echocardiography. The severity of TR was estimated using multiparametric assessment according to the guidelines. Mid-systolic 3D TA parameters were calculated using TV dedicated software. The conventional 2D systolic TA measurements in a standard four-chamber view were performed.ResultsIn mid-systole, the normal TA area was 9.2 ± 2.0 cm2 for men and 7.4 ± 1.6 cm2 for women. When indexed to body surface area (BSA), there were no significant differences in the 3D parameters between genders. The 2D TA diameters were smaller than those measured in 3D. The ROC curve analysis identified that all 3D TA parameters can accurately differentiate between different functional TR grades. Additionally, the optimal cut-off values were identified for each TA parameter.ConclusionsGender, body size, and age have an impact on the TA parameters in healthy subjects. 2D measurements are smaller than 3D parameters. The reference values for 3D metrics according to TR severity can help in identifying TA dilation and distinguishing between different functional TR grades.Graphical

Assessment of left ventricular function in patients with type 2 diabetes mellitus by non-invasive myocardial work.

Diabetes mellitus (DM) is a chronic disease that poses a serious risk of cardiovascular diseases. Therefore, early detection of impaired cardiac function with non-invasive myocardial imaging is critical for improving the prognosis of patients with DM. This study aimed to assess the left ventricular (LV) function in patients with type 2 diabetes mellitus (T2DM) by non-invasive myocardial work technique. In all, 67 patients with T2DM and 28 healthy controls were included and divided into a DM group and a control group. Two-dimensional dynamic images of apical three-chamber view, apical two-chamber view, and apical four-chamber view were collected from all subjects, consisting of at least three cardiac cycles. LV myocardial strain parameters, including global longitudinal strain (GLS) and peak strain dispersion (PSD), as well as myocardial work parameters, including global constructive work (GCW), global wasted work (GWW), global work index (GWI), and global work efficiency (GWE), were obtained and analyzed. A total of 15 subjects were randomly selected to assess intra-observer and inter-observer consistency of myocardial work parameters and strain parameters, which showed excellent results (intra-class correlation coefficients: 0.856 - 0.983, P<0.001). Compared with the control group, the DM group showed significantly higher PSD (37.59 ± 17.18 ms vs. 27.72 ± 13.52 ms, P<0.05) and GWW (63.98 ± 43.63 mmHg% vs. 39.28 ± 25.67 mmHg%, P<0.05), and lower GWE (96.38 ± 2.02% vs. 97.72 ± 0.98%, P<0.001). Furthermore, the PSD was positively correlated with GWW (r = 0.565, P<0.001) and negatively correlated with GWE (r = -0.569, P<0.001). Uncoordinated LV myocardial strain, higher GWW, and lower GWE in patients with T2DM may serve as indicators for the early assessment of cardiac impairment in T2DM.

Clinical Outcomes and Quality of Life after Patent Foramen Ovale (PFO) Closure in Patients with Stroke/Transient Ischemic Attack of Undetermined Cause and Other PFO-Associated Clinical Conditions: A Single-Center Experience.

The aim of this study was to assess clinical outcomes and quality of life after PFO closure in patients with previous stroke/TIA of undetermined cause and in patients with other complex PFO-associated clinical conditions. Between July 2009 and December 2019 at our University Cardiology Department, 118 consecutive patients underwent a thorough diagnostic work-up including standardized history taking, clinical evaluation, full neurological examination, screening for thrombophilia, brain magnetic resonance imaging (MRI), ultrasound-Doppler sonography of supra-aortic vessels and 24 h ECG Holter monitoring. Anatomo-morphological evaluation using 2D transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler and functional assessment using contrast TTE (cTTE) in the apical four-chamber view and contrast transcranial Doppler (cTCD) using power M-mode modality were performed to verify the presence, location and amount of right-to-left shunting via PFO or other extracardiac source. Completed questionnaires based on the Quality-of-Life Short Form-36 (QoL SF-36) and Migraine Disability Assessment (MIDAS) were obtained from the patients before PFO closure and after 12 months. Contrast TTE/TEE and cTCD were performed at dismission, 1, 6 and 12 months and yearly thereafter. Brain MRI was performed at 1-year follow-up in 54 patients. Transcatheter PFO closure was performed in 106 selected symptomatic patients (mean age 41.7 ± 10.7 years, range 16-63, 65% women) with the following conditions: ischemic stroke (n = 23), transient ischemic attack (n = 22), peripheral and coronary embolism (n = 2), MRI lesions without cerebrovascular clinical events (n = 53), platypnea-orthodeoxia (n = 1), decompression sickness (n = 1) and refractory migraine without ischemic cerebral lesions (n = 4). The implanted devices were Occlutech Figulla Flex I/II PFO (n = 99), Occlutech UNI (n = 3), Amplatzer PFO (n = 3) and CeraFlex PFO occluders (n = 1). Procedures were performed under local anesthesia and rotational intracardiac monitoring (Ultra ICE) alone. The devices were correctly implanted in all patients. The mean fluoroscopy time was 15 ± 5 min (range = 10-45 min) and the mean procedural time was 55 ± 20 min (range = 35-90 min). The total occlusion rate at follow-up (mean 50 months, range 3-100) was 98.1%. No recurrent neurological events were observed in the long-term follow-up. The data collected in this study demonstrate that percutaneous PFO closure is a safe and effective procedure, showing long-term prevention of recurrent cerebrovascular events, significant reduction in migraine symptoms and substantial improvement in quality of life.

Prenatal diagnosis of hypoplastic left heart syndrome: current knowledge.

Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the left-sided heart structures. The prenatal diagnosis of this congenital heart disease is crucial because a newborn with undiagnosed HLHS often presents with clinical signs of low cardiac output once the ductus arteriosus begins to close. With that in mind, the aim of this article was to perform a non-systematic review focusing on the key ultrasound features that can be used in the prenatal diagnosis of HLHS. Severe forms of HLHS are characterized by a markedly abnormal four-chamber view of the fetal heart (small left atrium, hypoplastic left ventricle, or abnormal mitral valve). The left ventricular outflow tract view allows the degree of hypoplasia in the tract to be evaluated and the diameter of the ascending aorta to be measured. The Z-scores are intended to aid in the diagnosis and follow-up of HLHS. In mild forms of HLHS, a right ventricle/left ventricle length ratio > 1.28 was the strongest predictor of a univentricular outcome.

Prenatal MRI assessment of mediastinal shift angle as a feasible and effective risk stratification tool in isolated right-sided congenital diaphragmatic hernia.

To develop a mediastinal shift angle (MSA) measurement method applicable to right-sided congenital diaphragmatic hernia (RCDH) in fetal MRI and to validate the predictive value of MSA in RCDH. Twenty-seven fetuses with isolated RCDH and 53 controls were included in our study. MSA was measured on MRI axial image at the level of four-chamber view of the fetal heart. The angle between the sagittal midline landmark line and the left boundary landmark line touching tangentially the lateral wall of the left ventricle was used to quantify MSA for RCDH. Appropriate statistical analyses were performed to determine whether MSA can be regarded as a valid predictive tool for postnatal outcomes. Furthermore, predictive performance of MSA was compared with that of lung area to head circumference ratio (LHR), observed/expected LHR (O/E LHR), total fetal lung volume (TFLV), and observed/expected TFLV (O/E TFLV). MSA was significantly higher in the RCDH group than in the control group. MSA, LHR, O/E LHR, TFLV, and O/E TFLV were all correlated with postnatal survival, pulmonary hypertension (PH), and extracorporeal membrane oxygenation (ECMO) therapy (p < 0.05). Value of the AUC demonstrated good predictive performance of MSA for postnatal survival (0.901, 95%CI: (0.781-1.000)), PH (0.828, 95%CI: (0.661-0.994)), and ECMO therapy (0.813, 95%CI: (0.645-0.980)), which was similar to O/E TFLV but slightly better than TFLV, O/E LHR, and LHR. We developed a measurement method of MSA for RCDH for the first time and demonstrated that MSA could be used to predict postnatal survival, PH, and ECMO therapy in RCDH. Newly developed MRI assessment method of fetal MSA in RCDH offers a simple and effective risk stratification tool for patients with RCDH. • We developed a measurement method of mediastinal shift angle for right-sided congenital diaphragmatic hernia for the first time and demonstrated its feasibility and reproducibility. • Mediastinal shift angle can predict more prognostic information other than survival in right-sided congenital diaphragmatic hernia with good performance. • Mediastinal shift angle can be used as a simple and effective risk stratification tool in right-sided congenital diaphragmatic hernia to improve planning of postnatal management.

Role of Fetal Cardiac MRI in Assessment of Congenital Heart Diseases in Comparison to Fetal Echocardiography

Introduction •Abnormalities of the cardiovascular system are the most common congenital diseases in the fetus and the first cause of infant mortality (Johnson et al. 2014). •Without a doubt, Echocardiography is the method of choice to visualize the fetal cardiac cardiovascular abnormalities. Unlike fetal echocardiography imaging, cardiovascular magnetic resonance (CMR) is relatively unaected by maternal and fetal conditions such as maternal obesity, uterine myoma, twins, oligohydramnios, fetal position and rib calcification, which particularly impair sonographic visualization of the fetal heart (Donofrio et al. 2014; Wielandner et al. 2013). •Fetal cardiac MR imaging is a novel MRI technique which can provide valuable information that could add to the prenatal diagnosis and evaluation of cardiac and most of extra-cardiac anomalies. The evaluation of pre-natal congenital cardiac anomalies is important for postnatal management. Aim of the work To highlight the advantage of MRI over fetal echocardiography in assessment of fetal congenital cardiac anomalies. Methods and material Twenty-six feti with suspected or diagnosed congenital cardiac anomalies. All cases underwent detailed history taking, fetal echocardiography and fetal cardiac MR. Study is approved by the ethics review board of Ain Shams University Hospital. Fetal echocardiography was done according to standard protocol and performed by suitable curvilinear probe. Then MRI of the fetal heart was done with uterine SURVEY_BFFE (balanced fast field echo), Black blood single shot -BH, white blood Cine, sBFFE_RLT DYN 3D(real time 3Ddynamic). Images were acquired in the transverse, four-chamber, shortaxis, coronal and oblique sagittal views. Findings of fetal echocardiography were compared with that of cardiac MRI. Results •Regarding the diagnostic performance of prenatal Echo and fetal cardiac MRI showed significant moderate agreement between the two modalities in the detection of different congenital cardiac anomalies, Kappa test: 0.500; p-value 0.021*. •Qualitative analysis: All cardiac structures were delineable by echocardiography and cardiac MRI. There was full agreement(κ = 1) between fetal echocardiography and cardiac MRI in evaluating the cardiac situs(24normal,1 levocardia, 1 ectopia cordis), aorta (20normal, 3 hypoplastic aorta,1 aortic stenosis,1 rt. Sided aortic arch and 1 small sized aorta), transverse cardiac diameter (22 normal, 4 cardiomegaly), foramen ovale (25 normal, 1 large single atrium), Good agreement was found between echocardiography and cardiac MRI for detection of position of the cardiac apex (23 normal, 2 dextrocardia and 1 mesocardia) •Fetal MRI had a significant role in detection of additional extracardiac anomalies in 13 cases. Conclusion fetal cardiac MR imaging as an adjunct to fetal echocardiography may provide valuable information that could add to the prenatal diagnosis and evaluation of cardiac and most of extra cardiac anomalies.