Long-axis View Research Articles

Echocardiogram Analysis Using Motion Profile Modeling.

Echocardiography is a widely used and cost-effective medical imaging procedure that is used to diagnose cardiac irregularities. To capture the various chambers of the heart, echocardiography videos are captured from different angles called views to generate standard images/videos. Automatic classification of these views allows for faster diagnosis and analysis. In this work, we propose a representation for echo videos which encapsulates the motion profile of various chambers and valves that helps effective view classification. This variety of motion profiles is captured in a large Gaussian mixture model called universal motion profile model (UMPM). In order to extract only the relevant motion profiles for each view, a factor analysis based decomposition is applied to the means of the UMPM. This results in a low-dimensional representation called motion profile vector (MPV) which captures the distinctive motion signature for a particular view. To evaluate MPVs, a dataset called ECHO 1.0 is introduced which contains around 637 video clips of the four major views: a) parasternal long-axis view (PLAX), b) parasternal short-axis (PSAX), c) apical four-chamber view (A4C), and d) apical two-chamber view (A2C). We demonstrate the efficacy of motion profile-vectors over other spatio-temporal representations. Further, motion profile-vectors can classify even poorly captured videos with high accuracy which shows the robustness of the proposed representation.

Statistical Analysis of M-Mode Echocardiographic Normal Reference Values in South Indian Adults

Background: Normal values for echocardiographic measurements are derived from American Society of echocardiography and European Society of Cardiology/European Association of Cardio-Vascular Imaging and their publications. Indians have smaller cardiac chamber dimensions than the Europeans. However, it has been long felt that reference range from western data cannot be fully applied in our scenario. Aim: The objective of this study was to develop age and gender-specific normative reference range values for echocardiography measurements. Methodology: This was a retrospective cross-sectional single-center study conduct on 111 healthy Indian adults who were selected out of the 336 patients aged from 18– 76 years, who visited the cardiac medical check-up unit in a tertiary hospital. Echocardiograms were done in participants free of cardiovascular diseases, hypertension, diabetes, high blood pressure or other clinical evident disorders. M-mode Echocardiography in the left parasternal long-axis view was used to measure aorta, left atrium, left ventricle in systole and diastole,right ventricle, interventricular septum, and posterior wall thickness. The 95% reference range of the echocardiographic parameters calculated as a mean±2 “standard deviation for overall and genders specific”. Results: This study provides a set of data with reference ranges for normal M-mode parameters according to age and gender. Around 58 males and 53 females were classified into the age group from 18-76 years as exclusive class intervals. Age group above of 38 years Indians had higher volume in all the echocardiographic measurements are observed in this study. On examining all our healthy participants, we found that the reference range of most echocardiographic parameters is a highly statistically significant difference as compared with those used in western studies. Conclusion: The normal reference values for echocardiographic measurements derived from this study could be used for future reference in our local population.

"Hourglass" Biceps Tendon: An Ultrasound "Mime" of Frozen Shoulder?

Supplemental Figure 1. Panoramic, long-axis view of the hourglass biceps tendon (white arrowheads) with associated effusion (yellow asterisks) inside the synovial sheath. Red arrowhead indicates anterior humeral circumflex artery. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Two-dimensional echocardiographic left- atrial-to-aortic ratio in healthy adult dogs: a reexamination of reference intervals

IntroductionLeft atrial-to-aortic ratios (LA:Ao) provide a body weight independent estimate of left atrial size. However, reference intervals were established with small sample populations and for only single points in the cardiac cycle. More robust reference intervals are warranted. AnimalsTwo hundred and thirty eight apparently healthy adult dogs. Materials and methodsLA:Ao measurements were obtained at 3 points in the cardiac cycle – maximal dimension, at the closing of the aortic valve (or just before opening of the mitral valve) (LA:AoMAX); minimal dimension, at the onset of the QRS complex (LA:AoMIN) and at the onset of atrial systole (LA:AoP). LA:AoMAX was obtained from right parasternal short and long-axis views, and LA:AoMIN and LA:AoP were obtained from the right parasternal short-axis view. Dogs were excluded from analyses of reference intervals if weight-based left atrial and left ventricular diastolic dimensions exceeded reference interval limits. Effects of breed and body weight on LA:Ao measurements were examined. ResultsUpper LA:Ao reference limits mostly agreed with previously published limits, although 10% of dogs had LA:AoMAX in the short-axis view exceeding 1.6. These dogs had smaller aortae than expected for their body weight, and included mostly boxers and English setters. Reference limits for LA:AoMIN and LA:AoP were smaller than those for LA:AoMAX in either view. No LA:Ao measurements were associated with body weight. ConclusionsReference limits were either confirmed or established for the common two-dimensional methods of assessing relative left atrial size in healthy dogs. Clinicians should use caution when diagnosing mild left atrial enlargement in certain dog breeds and should examine the weight-based aortic dimensions in such cases.

The predictive value of the epicardial adipose thickness in the rate of expansion of the aortic root.

Epicardial adipose tissue (ECAT) is metabolically active and is involved in the development of atherosclerosis. The thickness of ECAT has been positively correlated with the dimensions of the ascending aorta. We aimed to examine whether ECAT thickness predicted the expansion of the aortic dimensions. The imaging results of patients who had undergone transthoracic echocardiographic (TTE) examinations more than twice during the period 2005-2015 were surveyed. We included adult patients who had undergone TTE examinations at least 1year apart. The ECAT was measured in the parasternal long-axis view from the index TTE study. End-diastolic dimensions in three consecutive beats were averaged for all measurements. The annulus, root, and sinotubular junction (STJ) were also measured. The amount of increase (if any) in aortic dimensions per year was calculated and the correlation of this increase with the initial thickness of the ECAT was analyzed. In total, 429 examinations were performed with 197 patients (17females), from which 394 examinations were analyzed. The ECAT thickness was 8.6 ± 3.6 mm. In the initial examinations, the annulus, STJ, and root measured 23 ± 4, 28 ± 4, and 34 ± 4 mm, respectively. In univariate analysis, for every 1 mm of ECAT thickness, the STJ expanded 0.056 (95% CI: 0.001-0.112 mm/year; p = 0.030) and the aortic root expanded 0.088 mm/year (p < 0.001). In multivariate analysis, ECAT thickness remained an independent predictor of the aortic root expansion. For every 1‑mm increase in ECAT thickness, the aortic root expanded by 0.036 mm (95% CI: 0.010-0.062) per year (p = 0.007). The thickness of the ECAT is apredictor of more rapid increases in the dimensions of the aortic root. Further studies of patients with established aortic aneurysm are warranted.

Feature-Tracking Global Longitudinal Strain Predicts Mortality in Patients With Preserved Ejection Fraction: A Multicenter Study

ObjectivesThe goal of this study was to evaluate the prognostic value of global longitudinal strain (GLS) derived from cardiac magnetic resonance (CMR) feature-tracking in a large multicenter population of patients with preserved ejection fraction. BackgroundEjection fraction is the principal parameter used clinically to assess cardiac mechanics and provides prognostic information. However, significant abnormalities of myocardial deformation can be present despite preserved ejection fraction. CMR feature-tracking techniques now allow assessment of strain from routine cine images, without specialized pulse sequences. Whether abnormalities of strain measured by using CMR feature-tracking have prognostic value in patients with preserved ejection fraction is unknown. MethodsConsecutive patients with preserved ejection fraction (≥50%) and a clinical indication for CMR at 4 U.S. medical centers were included in this retrospective study. Feature-tracking GLS was calculated from 3 long-axis cine views. The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between GLS and death. The incremental prognostic value of GLS was assessed in nested models. ResultsOf the 1,274 patients in this study, 115 died during a median follow-up of 6.2 years. By Kaplan-Meier analysis, patients with GLS ≥ median (–20%) had significantly reduced event-free survival compared with those with GLS < median (log-rank test, p < 0.001). By Cox multivariable regression modeling, each 1% worsening in GLS was associated with a 22.8% increased risk of death after adjustment for clinical and imaging risk factors (hazard ratio: 1.228 per percent; p < 0.001). Addition of GLS in this model resulted in significant improvement in the global chi-square test (94 to 183; p < 0.001) and Harrell’s C-statistic (0.75 to 0.83; p < 0.001). ConclusionsGLS derived from CMR feature-tracking is a powerful independent predictor of mortality in patients with preserved ejection fraction, incremental to common clinical and imaging risk factors.

Relationship between left ventricular isovolumic relaxation flow patterns and mitral inflow patterns studied by using vector flow mapping

The purpose of this study was to investigate the relationship between isovolumic relaxation flow (IRF) patterns in left ventricle (LV) and mitral inflow patterns. Color Doppler loops were acquired for vector flow mapping in apical long-axis view in 57 patients with coronary artery disease, 31 patients with dilated cardiomyopathy, and 58 healthy controls. IRF patterns were classified into three categories: pattern A, apically directed flow; pattern B, bidirectional flow with small scattered vortices; and pattern C, a large vortex. All normals and patients with normal LV filling (n = 10) showed pattern A. Patients with impaired relaxation consisted of 31 (66%) patients having pattern A, 11 (23%) having pattern B, and 5 (11%) having pattern C. Patients with pseudonormal filling included 4 (31%) patients having pattern A, 7 (54%) having pattern B, and 2 (15%) having pattern C. In patients with restrictive filling, 14 (78%) showed pattern C, 4 (22%) showed pattern B, and no patient showed pattern A. IRF patterns were associated with LV filling patterns (χ2 = 52.026, p < 0.001). There are significant relationships between LV filling and IRF patterns. IRF patterns may provide an index for evaluation of LV diastolic function.

Global Tracking of Myocardial Motion in Ultrasound Sequence Images: A Feasibility Study.

The assessment of myocardial motion plays a promising role in the evaluation of cardiac function. This study aims to propose a novel framework of global estimation of the myocardial motion using radio-frequency (RF) data. The framework consists of B-mode image reconstruction, displacement estimation, myocardium extraction, and image fusion. The RF data of murine heart in parasternal long-axis (PLAX) view were collected for B-mode image reconstruction and displacement estimation. The vectorized normalized cross-correlation (VNCC) approach was proposed to globally estimate the displacements of the RF frames, while a sum-table based normalized cross-correlation (STNCC) was performed as reference algorithm. The bimodal fusion images were obtained to visualize the motion and anatomical structure of myocardium by an improved fast mapping algorithm (IFMA). In comparison with STNCC, the computation time of displacement using VNCC reduced by approximate 10s. The myocardial motions of anterior wall and posterior wall during one cardiac cycle were similarly tracked by VNCC as that of STNCC. The averaged absolute error in displacement between the two methods ranges from 1 to 3μm. The obtained myocardial elastographic images using VNCC intuitively present the morphological and mechanical changes during the contraction period of left ventricle. The results demonstrate that the proposed framework is an efficient tool for the estimation of myocardial motion reflecting cardiac systolic function. This approach has potentials to provide visualized information of myocardium for diagnosis and prognosis of cardiovascular diseases (CVDs).

Echocardiographic evaluation of the effects of sacubitril-valsartan on vascular properties in heart failure patients.

Increased vascular stiffness is known to be an independent predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). The effects of sacubitril-valsartan on vascular structure and function have not been systematically studied in this patient population. We hypothesized that aortic distensibility (AD) and fractional area change (AFAC), as assessed by 2D transthoracic echocardiography (TTE), would improve over time in HFrEF patients on sacubitril-valsartan therapy, due to the vasodilatory properties of the medication. We prospectively studied 30 patients with HFrEF (25 < EF < 40%) on optimal guideline-directed medical therapy who were subsequently started on sacubitril-valsartan. Patients underwent serial 2D TTE imaging at baseline, 3 and 6months following therapy initiation. Ascending aortic diameters were measured 3cm above the aortic valve in the parasternal long-axis view and used to calculate AD and AFAC, two markers of vascular compliance. For reference, we also measured AD and AFAC in 30 healthy, age and gender-matched controls at a single time point. Normal controls had significantly higher values of AD and AFAC than HFrEF patients at baseline (AD: 4.0 ± 1.1 vs. 2.2 ± 0.9 cm2dyne-110-3, p < 0.0001 and AFAC: 18.8 ± 3.7% vs. 10.3 ± 4.3%, p < 0.0001). In HFrEF patients on sacubitril-valsartan, both indices of aortic compliance progressively improved towards normal from baseline to 6months: AD from 2.2 ± 0.9 to 3.6 ± 1.5 cm2dyne-110-3 (p < 0.0001) and AFAC from 10.3 ± 4.3 to 13.7 ± 4.1% (p < 0.0001). In conclusion,AD and AFAC are decreased in patients with HFrEF and gradually improve with sacubitril-valsartan treatment. The echocardiographic markers used in this study may become a useful tool to assess the effectiveness of sacubitril-valsartan therapy in HFrEF patients.

P5253Does regional myocardial strain by cardiac magnetic resonance feature tracking reflect scar in ischemic heart disease?

Abstract Background Cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) is the gold standard for detection of myocardial scar. We hypothesized that CMR Feature Tracking (FT)-derived regional myocardial strain may reflect the presence of scar and could thus potentially be used instead of LGE imaging. Purpose The aim of this study was to determine the relationship between FT-derived regional myocardial strain and LGE in patients with coronary artery disease (CAD). Methods Seventy-five patients with CAD and typical ischemic LGE patterns on CMR (1.5T) were included (mean age 60±12 years, 70% males). Myocardial strain analysis and LGE identification were performed using dedicated commercial software. Scar was defined by presence of LGE in the same area of the myocardium in both short- and long-axis views. Peak systolic regional longitudinal and circumferential strain (RLS, RCS) values were calculated in the region of interest corresponding to the LGE area and also in a non-LGE myocardial region as a reference in each patient. These comparisons were repeated for a subgroup of 36 patients with left ventricular (LV) ejection fraction (EF) &lt;40% to determine whether the relationship between strain and LGE holds in the presence of reduced LV function, when strain measurements may be altered as a reflection of reduced LVEF itself. Results Both global longitudinal and circumferential strain values were abnormal (−12.8±5.1% and −11.4±4.1%, respectively), reflecting LV dysfunction in this CAD cohort (EF = 40±16%). The magnitude of both RLS and RCS was significantly reduced in areas of LGE, compared to those without LGE: RLS −10.0±5.8% versus −20.4±7.5% (p&lt;0.001); RCS −10.1±5.3±% versus −18.9±7.5%, respectively (p&lt;0.001). Same pattern was noted in the reduced EF subgroup: RLS −8.0±4.7% versus −16.9±6.6% (p&lt;0.001), RCS −7.7±4.3±% versus −16.0±7.9%, respectively (p&lt;0.001). The figure depicts 2 representative cases in long and short axis views, LGE detection and concomitant regional strain analysis. LGE and regional strain analysis. Conclusion Reduced magnitude of regional longitudinal and circumferential strain by CMR-FT correlates with presence of LGE. Pending further validation, this finding may constitute the basis for detection of scar without contrast enhanced imaging, and would result in reduced cost, scan time and risk associated with gadolinium. Acknowledgement/Funding ARP: Research support (software) from Neosoft and Philips

P6458The prevalence of left ventricular non-compaction in newborns

Abstract Background Pronounced trabeculation of the left ventricular myocardium, or non-compaction, may be accompanied by systolic dysfunction in ventricular non-compaction cardiomyopathy (LVNC). It is unclear whether non-compaction represents a fetal development defect or may develop later in life. Previous studies have estimated the prevalence of non-compaction to 0.01–0.31% in adults referred for echocardiography. The prevalences in unselected populations of adults or children are unknown. Purpose To determine the prevalence of non-compaction of the left ventricle in a large population-based cohort of newborns and to assess the relation to left ventricular systolic function. Methods Transthoracic echocardiography was performed according to a standardized protocol in all newborns included in a regional population-based cohort study in 2016–2018. For the present study, the extent of trabeculations were assessed by one of three primary reviewers in apical long-axis views (4-chamber, 5-chamber, and sinus coronarius views), parasternal short (SAX), and long axis (PLAX) views. Based on the presence of pronounced trabeculations, deep intertrabecular recesses and/or an impression of a ratio of &gt;1 of non-compact:compact myocardium (NC:C), the exam was regarded as either possible or not possible non-compaction: In examinations classified as possible non-compaction, an expert reviewer would determine if diagnostic criteria were fulfilled. A ratio of NC:C myocardium ≥2 was considered as non-compaction in accordance with previously suggested criteria. Results As of January 11, 2019, 6,880 neonate echocardiograms (median age 10 days [IQR 5,14], 48.8% females) had been analyzed. In total, 127 (1.8%) were considered as possible non-compaction. Six newborns (median age 14 days [IQR 8,18], 33.3% females) had a ratio of NC:C myocardium ≥2 corresponding to a prevalence of non-compaction of 8.7 per 10,000 newborns (95% CI 0.04–0.19%) (Figure). One of six neonates had a ratio of NC:C myocardium≥2 in more than one segment. Median fractional shortening (FS %), left ventricular end-diastolic (LVIDd) and end-systolic diameter (LVIDs) were 29.5% (IQR 27.0, 31.0), 1.9 cm (IQR 1.8, 2.1) and 1.3 cm (IQR 1.3, 1.5) respectively in the six newborns with non-compaction. The corresponding mean z-scores (standard deviations away from the age-matched reference mean) according to The Boston Children's Hospital z-score Calculator were FS: r=−3.0 (IQR r=−3.8, r=−2.5), LVIDd: r=−1.3 (IQR r=−2.7, r=−0.2), LVIDs: 0.2 (IQR r=−0.1, 1.6). 10-days-old boy with LVNC (FS 22%) Conclusion Echocardiography of an unselected population-based cohort of 6,880 newborns revealed a prevalence of non-compaction of 8.7 per 10,000 newborns. The prevalence is in accordance with previously described prevalences in adults referred for echocardiography and corroborate the view that non-compaction may be a fetal developmental defect. Non-compaction was not associated with left ventricular dilatation but with systolic dysfunction. Acknowledgement/Funding Danish Heart Association, Danish Children's Heart Foundation, Candy's Found., Toyota Found., Herlev-Gentofte Hospital Research Found., Gangsted Found.

P3836Myocardial work distribution in hypertensive patients with basal septal hypertrophy - a non-invasive assessment with left ventricular pressure-strain relations

Abstract Background and aim Localized basal septal hypertrophy (BSH) is a known marker of hypertension. However, the underlying functional significance of this morphologic finding is not clear. Non-invasive LV pressure estimates and speckle-tracking deformation curves can be used to quantify myocardial work (MW), which may offer insights into work distribution in increased afterload leading to better understanding of the early changes in hypertensive heart disease. The aim is to assess segmental strain and MW indices in hypertensive patients with and without BSH, as well as in healthy controls. Methods An echocardiogram was performed on a total of 149 patients with a diagnosis of long-standing hypertension and on 19 healthy age and sex-matched controls. The septum was measured at basal and mid-level in parasternal long-axis and four-chamber views. A two-part criterion - a positive visual assessment of an abrupt change in septal thickness seen in the 4C or PLAX view and a basal to mid-septal ratio ≥1.4 - was used to identify BSH. LV speckle-tracking was performed in 4C, 2C, and 3C views. Myocardial work index was calculated between mitral valve closing and opening. Average regional values of strain and MW indices were calculated by averaging the 4C, 3C, and 2C basal, mid, and apical segments. Results BSH was present in 19.2% (n=28) of the hypertensive cohort. There were no differences in LV ejection fraction or global longitudinal strain between the subgroups. The basal inferoseptum and anteroseptum were thicker in the hypertensive patients, significantly more so in the BSH subgroup, which was coupled with a proportional decrease in local deformation. Averaged regional deformation values showed a gradient increasing from base to apex in all subgroups, more pronounced in the BSH patients due to significantly impaired average basal deformation (controls vs. non-BSH vs. BSH: −18.33±1.92 vs. −17.24±2.14 vs. −15.56±2.08%, p&lt;0.001). This deformation pattern was reflected in myocardial work distribution in hypertension, showing the basal region performing a lower percentage of global work, especially so in the BSH patients, while the apical region performed a significantly higher percentage, with a trend of further increase in the BSH subgroup (Figure 1). Figure 1 Conclusion Localised BSH, a structural finding in one-fifth of the hypertensive population, is related to functional impairment in regional systolic deformation and a pronounced redistribution of myocardial work during the cardiac cycle. An apex-to-base gradient in myocardial work signals an apical compensation of basal impairment in the setting of increased afterload. Clinical follow-up of patients is needed in order to assess the prognostic relevance of these findings. Acknowledgement/Funding Spanish Ministry of Economy and Competitiveness (TIN2014-52923-R), Fundacio La Maratό de TV3 (040310), H2020-MSCA-ITN-2016 (764738)

P3365Relationship between early diastolic intra-ventricular pressure gradient shortly after aortic valve closure estimated by vector flow mapping and left ventricular diastolic untwisting rate in humans

Abstract Background Early diastolic suction is an important determinant of early diastolic function. Previous studies using color Doppler M-mode and speckle-tracking echocardiography have shown left ventricular (LV) early diastolic LV untwisting rate is directly related to LV intra-ventricular pressure gradient (IVPG) between LV base and apex during early diastole. Recent introduction of vector flow mapping (VFM) using combination of color Doppler and speckle-tracking echocardiography provides noninvasive and feasible assessment of early diastolic IVPG shortly after aortic valve closure including isovolmic relaxation period (ED-IVPG) in humans. However, relationship between VFM–derived ED-IVPG and early diastolic LV untwisting rate has not been well investigated. Purpose The purpose of this study was to examine relationship between ED-IVPG estimated by VFM and LV untwisting rate by speckle-tracking echocardiography. Methods The study population consists of 66 patients without segmental wall motion abnormality, significant valvular diseases, and atrial fibrillation who underwent echocardiography for evaluation of LV function (age: 60±15 years, LVEF: 49±16%). From the apical long-axis views by color Doppler echocardiography, we analyzed peak ED-IVPG between LV base and apex just after aortic valve closure (figure) using commercially available VFM analysis software (DAS-RS1, Hitachi). We assessed peak early diastolic LV untwisting rate and LV torsion from LV basal and apical short-axis view by speckle-tracking echocardiography. We evaluated correlation between ED-IVPG and LV untwisting rate. We also evaluated correlation between ED-IVPG and peak systolic LV torsion, LV end-diastolic (EDV) and end-systolic volumes (ESV), ejection fraction (EF), early diastolic velocity (E) of LV inflow, average early diastolic velocity (e') of mitral annulus, and average E/e'. Results In all the study patients, ED-IVPG was successfully and quickly evaluated. 1) ED-IVPG correlated well with peak LV untwisting rate (r=0.64, p&lt;0.0001). 2) ED-IVPG significantly correlated with LV torsion, LVEDV, LVESV, and LVEF (r=0.47, r=−0.48, r=−0.46, and r=0.48, respectively, p&lt;0.001). 3) There were no significant correlations between ED-IVPG and other indexes including E, average e', and average E/e'. According to receiver operating characteristic analysis, the best cut-off value of ED-IVPG for determining impaired LV untwisting rate (&lt;80 degrees/s) was found at 0.42 mmHg (sensitivity 81%, specificity 76%, and area under the curve 0.86) ED-IVPG measurement by VFM Conclusions The present results showed that noninvasive VFM-derived peak ED-IVPG shortly after aortic valve closure is related to early diastolic peak LV untwisting rate. ED-IVPG easily and quickly estimated by VFM may be used as an additional index for LV diastolic function.

P2477Assessment of intraventricular flow dynamics in acute heart failure studied by Vector Flow Mapping

Abstract Background Although left ventricular (LV) flow dynamics should be closely related to LV morphology and function, little is known about how heart failure (HF) changes it. Pathline Analysis (PA), a recently developed software based on Vector Flow Mapping (VFM, Hitachi), enables us to trace the virtual blood particles entering to the LV in diastole and being ejected in systole. We investigated the change of flow dynamics in HF induced in dogs using PA. Methods In 15 open-chest dogs, HF was induced by intracoronary injection of microspheres. Color Doppler images of apical long-axis view were acquired using Prosound F75 (Hitachi) before and after HF and were analyzed by PA. We calculated the ratio of the numbers of entering particles in diastole and ejected particles in systole (ejection rate) and the distance reached by the particles in diastole corrected by the LV long-axis diameter (propagation distance). Apical and basal short axis images were acquired using GE Vivid E9 and were analyzed for peak rotation and peak twist. Results After inducing HF, LV end-diastolic pressure increased from 6±2 to 15±5 mmHg (p&lt;0.001) and ejection fraction (EF), apical peak rotation and peak twist decreased significantly (EF; 58±5 to 36±8%, apical peak rotation; 14±5 to 3±2 degree, peak twist; 19±5 to 6±3 degree, p&lt;0.05, respectively). PA showed most of the entering particles to the LV were ejected in the following systole at the control stage, but in HF, a significant part of the entering particles were not ejected and remained in the LV (Figure). Ejection rate decreased from 50±11 to 26±11% (p&lt;0.001) and the propagation distance decreased from 85±9 to 66±13% (p&lt;0.001) after inducing HF. There were significant relationships between indices obtained by PA and EF and peak twist (Table). Conclusion A significant part of inflow is not ejected directly to the outflow in the next systole and remains in the LV in HF, suggesting inefficient flow dynamics.

P2646Determinants of aortic root dilatation over time in hypertensive treated patients: the Campania Salute Network

Abstract Background We demonstrated that aortic root (AR) dilatation assessed by standardized difference between observed and predicted values is present at baseline in about 30% of treated hypertensive patients and predicts cardiovascular (CV) events independently of left ventricular (LV) hypertrophy (LVH). Purpose We investigate whether a CV phenotype exists predicting AR dilatation during follow-up of treated hypertensive patients. Methods 5301 hypertensive treated patients (age 53±11 years, 42% women) without prevalent CV disease and with normal ejection fraction (≥50%) were studied. AR dimension was measured in the parasternal long-axis view at the level of sinus of Valsalva in end-diastole, using the leading-edge to leading-edge method at first and last available echocardiograms. The z-score of AR dimension (AOz) was generated based on the difference between observed AR and predicted AR dimension, divided by sex-specific observed SD. Results Initial AOz exhibited a normal distribution and was correlated positively with age, male sex, systolic and diastolic blood pressure (BP), BMI, fasting glucose, and glomerular filtration rate (GFR, by EPI-CKD) and negatively with pulse pressure (PP) and cholesterol (all 0.0375th percentile of the AOz distribution). Similar to baseline, initial SVi and BMI remained the most potent covariates of the final AOz (both p&lt;0.0001), independently of significant effect of male sex, high diastolic BP, BMI, SVi, low PP, and low HDL-cholesterol. Variance inflation factor was &lt;2 in both regression models. Figure shows initial SVi in relation with AR at follow up. Conclusions We demonstrate that both volume (SVi) and pressure loads (diastolic BP) influence AR enlargement over time, AR dilatation is predictable in male obese patients with diastolic hypertension and other metabolic disturbances.

A new measurement site for echocardiographic epicardial adipose tissue thickness and its value in predicting metabolic syndrome.

Echocardiographic epicardial adipose tissue (EAT) thickness is defined as the thickness of the low-isoechoic area on the free wall of the right ventricle in the parasternal long-axis and short-axis views. Recent studies have suggested that it might support current risk stratification strategies in identifying an increased risk of metabolic syndrome. The aim of this study is to explore a new measurement site which can better reflect EAT thickness and to assess its value in predicting metabolic syndrome. A total of 975 Chinese adults were measured for EAT thickness on the right ventricular anterior free wall (EAT-rv) and on the anterior interventricular groove (EAT-ivg) with echocardiography. The correlation between EAT thickness and metabolic syndrome was analyzed, as was the agreement between epicardial adipose volume (EAV) and EAT thickness. Independent risk factors of EAT thickness were identified and the predictive value of EAT thickness was assessed. Epicardial adipose tissue thickness was higher in older participants and those with obesity, diabetes, hypertension, hypertriglyceridemia, and metabolic syndrome, and it was lower in male participants. The EAT-ivg was higher in the participants with hypo-high-density-lipoprotein cholesterolemia than in those without the disorder, but the EAT-rv values were not statistically different. The kappa value was 0.524 between EAT-rv and EAV, and 0.783 between EAT-ivg and EAV. Advanced age, large waist circumference and female gender were independent risk factors of high EAT-ivg, while high-density-lipoprotein (HDL) cholesterol was a protective factor. The EAT-ivg was associated with metabolic syndrome. The area under the curve of EAT-ivg applied in predicting metabolic syndrome was greater than that of EAT-rv (0.715 vs 0.648). The EAT-ivg was more consistent with EAV than EAT-rv, was independently associated with metabolic syndrome and had a higher value in predicting metabolic syndrome than EAT-rv. Therefore, the anterior interventricular groove can serve as a new measurement site which better reflects EAT thickness.

Comparison of long-, short-, and oblique-axis approaches for ultrasound-guided internal jugular vein cannulation: A network meta-analysis.

Comparison between various approaches of ultrasound (USG)-guided internal jugular vein cannulation, that is, short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach, is sparse. In this network meta-analysis of randomized controlled trials, all three approaches were evaluated to identify the best technique for USG-guided internal jugular vein cannulation. Randomized controlled trials comparing short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach in any combination (i.e. comparison of any two or all three) for USG-guided internal jugular vein cannulation were included in this meta-analysis. Bayesian network meta-analysis was conducted with a non-informative prior effect size and heterogeneity, and all results were reported as posterior median odds ratio with 95% credible interval. Data of 658 patients from five randomized controlled trials were included in this meta-analysis. No difference was obtained in first attempt success rate of cannulation in three approaches (posterior median odds ratio between long-axis and short-axis view, oblique-axis and short-axis view, and long-axis and oblique-axis view were 0.67 (0.20, 2.08), 0.92 (0.09, 4.790), and 1.3420 (0.1680, 6.7820), respectively). No difference was seen in the incidence of carotid artery puncture and overall success rate of cannulation. All three commonly used approaches for USG-guided internal jugular vein cannulation, that is, short axis, long axis, and oblique axis, are comparable in terms of clinical utility and safety. There is insufficient evidence to recommend one approach over another for this purpose.

Factors influencing the end‐diastolic vortex assessed by using vector flow mapping

The purpose of this study was to assess the factors influencing the late diastolic vortex in normal and abnormal ventricles. Color Doppler data in left ventricle (LV) were acquired from apical long-axis view and analyzed using vector flow mapping in 57 patients with coronary artery disease, 57 patients with dilated cardiomyopathy, and 53 healthy volunteers. In normals, corrected area and flux of the end-diastolic vortex were positively correlated with transmitral A velocity and heart rate. Subjects with E/A <1 had higher vortex flux than those with E/A >1. Heart rate was the only independent predictor of corrected vortex area (R2 =.170, P=.004), and transmitral A velocity and heart rate were the independent predictors of corrected vortex flux (R2 =.490, P<.001). Patients with various mitral filling patterns showed significant differences in vortex area and flux. The vortex area and flux were positively correlated with transmitral i velocity and a'. Transmitral A velocity was the only independent predictor of corrected vortex area (R2 =.180, P<.001), while transmitral A velocity, heart rate, LV end-systolic short diameter, and end-diastolic long diameter were the independent determinants of corrected vortex flux (R2 =.593, P<.001). The end-diastolic vortex is formed and mainly affected by the late LV filling. The compensatory atrial contraction may enhance the end-diastolic vortex that facilitates coupling between diastole and systole. LV size can influence the end-diastolic vortex in patients with LV dysfunction and enlargement.

Interplay of cardiac remodelling and myocardial stiffness in hypertensive heart disease: a shear wave imaging study using high-frame rate echocardiography

To determine myocardial stiffness by means of measuring the velocity of naturally occurring myocardial shear waves (SWs) at mitral valve closure (MVC) and investigate their changes with myocardial remodelling in patients with hypertensive heart disease. Thirty-three treated arterial hypertension (HT) patients with hypertrophic left ventricular (LV) remodelling (59 ± 14 years, 55% male) and 26 aged matched healthy controls (55±15 years, 77% male) were included. HT patients were further divided into a concentric remodelling (HT1) group (13 patients) and a concentric hypertrophy (HT2) group (20 patients). LV parasternal long-axis views were acquired with an experimental ultrasound scanner at 1266 ± 317 frames per seconds. The SW velocity induced by MVC was measured from myocardial acceleration maps. SW velocities differed significantly between HT patients and controls (5.83 ± 1.20 m/s vs. 4.04 ± 0.96 m/s; P < 0.001). In addition, the HT2 group had the highest SW velocities (P < 0.001), whereas values between controls and the HT1 group were comparable (P = 0.075). Significant positive correlations were found between SW velocity and LV remodelling (interventricular septum thickness: r = 0.786, P < 0.001; LV mass index: r = 0.761, P < 0.001). SW velocity normalized for wall stress indicated that myocardial stiffness in the HT2 group was twice as high as in controls (P < 0.001), whereas values of the HT1 group overlapped with the controls (P = 1.00). SW velocity as measure of myocardial stiffness is higher in HT patients compared with healthy controls, particularly in advanced hypertensive heart disease. Patients with concentric remodelling have still normal myocardial properties whereas patients with concentric hypertrophy show significant stiffening.

Epicardial Adipose Tissue in Patients with Takotsubo Cardiomyopathy

Background Takotsubo Cardiomyopathy (TCM) is characterized by transient dysfunction of the left ventricle involving apical hypokinesis and basal hyperkinesis in the absence of obstructive coronary artery disease (CAD). Triggers include emotional and physical stressors. Epicardial adipose tissue (EAT) has been shown to be metabolically active by producing cytokines and inflammatory markers. Studies have shown correlation of increased EAT with metabolic syndrome, CAD, heart failure and atrial fibrillation. We seek to investigate whether increased EAT contributes to TCM. Methods We analyzed transthoracic echocardiograms (TTE) of patients with and without TCM. EAT was defined as the hypoechoic area from the outer wall of the myocardium to the visceral layer of the pericardium, determined from the parasternal long-axis view. EAT was measured perpendicularly from the free wall of the right ventricle during systole. EAT thickness from three cardiac cycles were measured. Results Twenty-five patients with TCM and a control group of 25 patients without TCM, matched for similar baseline characteristics were enrolled. EAT thickness was 5.3mm ± 1.3 mm in TCM patients and 4.5 ± 1.4 mm in the non-TCM group (p Conclusions Our study demonstrates patients with TCM have increased EAT thickness, which we hypothesize may play a role in the pathogenesis of TCM.