Short-axis View Research Articles

S-52-3: ROLE OF NOVEL ECHOCARDIOGRAPHIC METHODS TO DETECT EARLY MYOCARDIAL DYSFUNCTION IN WOMEN WITH PREECLAMPSIA

Normal pregnancy is associated with reversible changes in both systolic and diastolic mechanics, consistent with an increase in preload and decrease in afterload and systemic vascular resistance. The aim of the study is to evaluate left ventricular cardiac mechanics via speckle tracking echocardiography in a population of pregnant women with per partum cardiomyopathy and preeclampsia(PE) after invitro fertilization (IVF) during different stages of pregnancy. The study population included 525 pregnant women with PE, after IVF, 100 of them with multiple pregnancy (46.5 ± 3 years) and 30 healthy nonpregnant women (33 ± 4years).Apical and basal short axis and apical view for three, two and four chamber for 2D images were acquired (65 ± 7 frames/s) during the first, second and third trimester of the pregnancy, as well as up to two months post partum. The curves of longitudinal(GLS), circumferential(GCS), radial strain(GRS) and LVT /LVUR were extracted using a commercial software. Results: Peak LVT and LVUR increased significantly in the 3rd trimester in both pregnancy groups (13.48 ± 2.90°,13.12 ± 3.30?,16.83 ± 3.61?,P < 0.001; and -111.52 ± 23.54°/sec,-107.40 ± 26.58?/sec,-144.30 ± 45.14?/sec, P < 0.001; in the 1st, 2nd, and 3rd trimester, respectively.The pregnants with twins have the highest value for LVT and LVUR compare with other pregnants (p < 0.01), but in the last trimester, the time to peak LVUR is prolonged. An independent correlation was found between the change in LVT and LV end-systolic volume in 1st and 3rd trimester (r = 0,56). Peak LVUR at the 3rd trimester correlated significantly with LV end-diastolic volume. Multiple regression analysis indicates that only systolic blood pressure (r = 0.394, P = 0.005) was an independent predictor for increased LV torsion. Arterial hypertension (AH) and prevalence of preeclampsia (PE) are more often in IVF group. Longitudinal strain decreased significantly (p < 0.001) during 3th trimester in women with AH and PE. Global longitudinal strain measures of the LV were non-significantly different between the different groups in first and second trimester (GLS-20.6 ± 3,14 vs.-19,29 ± 2,17).There are not found significant differences for GCS and GRS during pregnancy. Conclusions: During pregnancy LV twist and peak untwisting rate increase in the 3rd trimester and correlate with end-systolic and end-diastolic volume, respectively. Blood pressure and condition of multiple pregnancy are independently associated with increased torsion during pregnancy and may predict the new onset heart failure and perinatal cardiomyopathy. Global longitudinal strain is the main predictor of new onset peripartum cardiomyopathy

Transmural Wave Speed Gradient May Distinguish Intrinsic Myocardial Stiffening From Preload-Induced Changes in Operational Stiffness in Shear Wave Elastography.

Shear wave elastography (SWE) is a promising technique to non-invasively assess myocardial stiffness based on the propagation speed of mechanical waves. However, a high wave propagation speed can either be attributed to an elevated intrinsic myocardial stiffness or to a preload-induced increase in operational stiffness. Our objective was to find a way to discriminate intrinsic myocardial stiffening from stiffening caused by an increased pressure in SWE. We used the finite element method to study the shear wave propagation patterns when stiffness and/or pressure is elevated, compared to normal stiffness and pressure. Numerical findings were verified in a few human subjects. The transmural wave speed gradient was able to distinguish changes in intrinsic stiffness from those induced by differing hemodynamic load (a speed of ±3.2 m/s in parasternal short-axis (PSAX) view was associated with a wave speed gradient of -0.17 ± 0.15 m/s/mm when pressure was elevated compared to 0.04 ± 0.05 m/s/mm when stiffness was elevated). The gradient however decreased when stiffness increased (decrease with a factor 3 in PSAX when stiffness doubled at 20 mmHg). The human data analysis confirmed the presence of a wave speed gradient in a patient with elevated ventricular pressure. Cardiac SWE modeling is a useful tool to gain additional insights into the complex wave physics and to guide post-processing. The transmural differences in wave speed may help to distinguish loading-induced stiffening from intrinsic stiffness changes. The transmural wave speed gradient has potential as a new diagnostic parameter for future clinical studies.

Radiomic analysis of enhanced CMR cine images predicts left ventricular remodeling after TAVR in patients with symptomatic severe aortic stenosis.

This study aimed to develop enhanced cine image-based radiomic models for non-invasive prediction of left ventricular adverse remodeling following transcatheter aortic valve replacement (TAVR) in symptomatic severe aortic stenosis. A total of 69 patients (male:female = 37:32, median age: 66 years, range: 47-83 years) were retrospectively recruited, and severe aortic stenosis was confirmed via transthoracic echocardiography detection. The enhanced cine images and clinical variables were collected, and three types of regions of interest (ROIs) containing the left ventricular (LV) myocardium from the short-axis view at the basal, middle, and apical LV levels were manually labeled, respectively. The radiomic features were extracted and further selected by using the least absolute shrinkage and selection operator (LASSO) regression analysis. Clinical variables were also selected through univariate regression analysis. The predictive models using logistic regression classifier were developed and validated through leave-one-out cross-validation. The model performance was evaluated with respect to discrimination, calibration, and clinical usefulness. Five basal levels, seven middle levels, eight apical level radiomic features, and three clinical factors were finally selected for model development. The radiomic models using features from basal level (Rad I), middle level (Rad II), and apical level (Rad III) had achieved areas under the curve (AUCs) of 0.761, 0.909, and 0.913 in the training dataset and 0.718, 0.836, and 0.845 in the validation dataset, respectively. The performance of these radiomic models was improved after integrating clinical factors, with AUCs of the Combined I, Combined II, and Combined III models increasing to 0.906, 0.956, and 0.959 in the training dataset and 0.784, 0.873, and 0.891 in the validation dataset, respectively. All models showed good calibration, and the decision curve analysis indicated that the Combined III model had a higher net benefit than other models across the majority of threshold probabilities. Radiomic models and combined models at the mid and apical slices showed outstanding and comparable predictive effectiveness of adverse remodeling for patients with symptomatic severe aortic stenosis after TAVR, and both models were significantly better than the models of basal slice. The cardiac magnetic resonance radiomic analysis might serve as an effective tool for accurately predicting left ventricular adverse remodeling following TAVR in patients with symptomatic severe aortic stenosis.

937 INCIDENTAL DIAGNOSIS OF ANOMALOUS ORIGIN AF A CORONARY ARTERY: BETTER LATE THAN NEVER.

Abstract Background Anomalous origin of the left circumflex coronary artery (LCx) from the right sinus of Valsalva (RSV) is the most frequent among anomalous aortic origin of the coronary arteries (AAOCA). The estimated prevalence is low (about 0.4%) and in most cases asymptomatic. Angina, shortness of breath, myocardial infarction has been described in some patients, although diagnostic and therapeutic management is controversial, particularly in elderly patients. Case presentation A 76-year-old female patient was admitted to our outpatient clinic for dyspnea and chest discomfort. In clinical history hypertension, dyslipidemia and diabetes were documented. Hemodynamic parameters, clinical examination and ECG were normal. Transthoracic echocardiography showed preserved global systolic function without abnormalities of regional kinesis and valvular diseases were excluded. Interestingly, in five chambers apical view, a binary structure in the atrioventricular groove above the mitral valve plane that seemed to cross the aorta perpendicularly (RAC sign) was detected. Furthermore, in parasternal short axis view, we visualized the origins of the left and right coronaries and a blood vessel behind the aortic root, as well as a small circle below the non-coronary aortic cusp in mitroaortic angle in the parasternal long axis view (Bleb sign) was identified. We hypothesized an anomalous origin of LCx from the RSV with a retroaortic anomalous course and this was confirmed by coronary computed tomography (coroCT), that excluded an intramural course and critical stenosis of coronary arteries. Finally, we decided to perform an exercise stress echocardiography which excluded inducible myocardial ischemia. Pharmacological therapy was optimized and clinical follow-up was unremarkable. Conclusions AAOCA may be incidentally diagnosed also in advanced age. Specific echocardiographic signs should suggest more advanced imaging techniques to confirm the diagnostic suspect. Non-invasive multimodality imaging is crucial, in order to exclude inducible myocardial ischemia and to avoid more invasive and harmful diagnostic tests.

1050 ULTRASOUND GUIDED CANNULATION OF FEMORAL ARTERY IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Abstract Background Vascular access complications are a significant source of morbidity and mortality after transcatheter aortic valve replacement (TAVR). Ultrasound-guided cannulation (UGC) of central veins or arteries is a widely used approach for patients undergoing invasive procedures. Whether UGC significantly decreases the risk of vascular access complications also for large-bore access procedures, such as TAVR, lacks evidence Objectives in this study, we aimed to evaluate the benefits of routine use of UGC in patients undergoing TAVR. Methods Data were retrospectively collected from two high-volume TAVR centers from September 2009 to March 2022. UGC was performed using a two-dimensional ultrasound short-axis views, while manual palpation, fluoroscopy, or contralateral angiography were used for the other patients. The odds ratio (OR) for vascular complications was calculated using a multivariate logistic regression model including as dependent variables all relevant baseline and procedural characteristics (forward stepwise selection process). Vascular complications were adjudicated according to the Valve Academic Research Consortium definitions 3. Results Out of 874 patients included in the study, UGC access was performed in 177 subjects. Overall mean age was 80.2±5.8 years old, 60% of patients were females, 35.5% had diabetes, 61.4% had dyslipidemia, and 27.8% had chronic kidney disease, with a mean left ventricular ejection fraction of 52.7±9.7%. Looking at the procedural variables Euroscore II was 5.8±5.4, second and third valves generation have been used in 85% of the cases, while suture-based closure devices in 84% of subjects. After adjustment for clinical and procedural variables, routinely use of UGC was associated with a lower rate of total [Odds Ratio (OR): 0.38; 95% confidence interval (CI) 0.15% to 0.95%)] and major vascular complications [Odds Ratio (OR): 0.21; 95% confidence interval (CI) 0.05% to 0.75%)], while no differences were observed for minor vascular complications. Conclusions Routinely use of UGC significantly decreases the risk of vascular complications in patients undergoing TAVR. However, a dedicated randomized clinical trial assessing the safety and efficacy of this approach is warranted to confirm our results in this high-risk population.

1116 DOUBLE-CHAMBERED RIGHT VENTRICLE AND VENTRICULAR SEPTAL DEFECT IN AN ELDERLY WOMAN: A RARE CASE.

Abstract Introduction Double-chambered right ventricle (DCRV) is a rare congenital heart defect with right ventricular outflow tract (RVOT) obstruction. The right ventricle (RV) is divided into anatomically proximal high-pressure and distal low-pressure chambers by abnormal muscle bundle. DCRV is frequently associated with others congenital heart defects, particularly ventricular septal defects (VSDs). Although its typically presents during childhood and adolescence, it can also present in adulthood. Case Presentation An 84-years-old woman was admitted to our hospital, in emergency department, with a 30-days history of worsening dyspnea and exercise intolerance. She was Ukrainian and did not speak Italian or English. The patient past medical history was unknow except for untreated bilateral glaucoma complicated by blindness. Vital signs were notable for tachycardia, tachypnea (respiratory rate, 28/minute), blood pressure of 118/76 mm Hg, SpO2 of 91%. Physical exam revealed left-sided parasternal systolic murmurs, abolished vesicular murmur at lung bases and jugular vein distension with hepatojugular reflux. The ECG showed atrial fibrillation. Chest X-ray showed moderate cardiomegaly, bilateral pleural effusions, and pulmonary congestion. Transthoracic echocardiography (TTE) was performed and revealed a normal-sized left ventricle with mildly reduced left ventricle ejection fraction (EF 48%), left atrial enlargement, biventricular hypertrophy with asymmetrical interventricular septal hypertrophy. Also, we found massive right atrium and enlarged right ventricle with reduced longitudinal contractility (TAPSE of 13 mm and tricuspid annular tissue Doppler S’ velocity = 7.0 cm/sec). Color flow Doppler in parasternal short-axis view revealed a turbulent systolic flow into the right ventricle. Continuous-wave spectral Doppler analysis showed a peak velocity of 5.6 m/ sec corresponding to a peak gradient of 120 mmHg. Real time 3D-TTE confirmed the of mid-ventricular obstruction due to abnormal trabecular tissue. Therapy including diuretics, beta-blockers and anticoagulants was started. Subsequently, a transesophageal echocardiography (TOE) confirmed the presence of an anomalous mid-ventricular muscle bundle and revealed an associated small sub-aortic ventricular septal defect (VSD) leading to the diagnosis of acute RV failure due to double-chambered RV with VSD and atrial fibrillation. Due to the high risk of complications, patient was considered not amenable for surgery. She was discharged on medical therapy. Conclusions We report a rare case of DCRV and VSD diagnosed in an elderly patient. Due to its rarity, DCRV continues to be misdiagnosed, especially in adulthood. Three-dimensional echocardiography and TOE were most useful tool to define diagnosis and pathophysiology in such an elderly and non-compliant patient.

898 ROLE OF 3D ECHOCARDIOGRAPHY IN AORTIC VALVE ABNORMALITIES: TWO CASES REPORT

Abstract Introduction Aortic valves with a number of cusps different from two or three are infrequent congenital anomalies that might manifest with valvular disease in young patients. We present two cases of unicuspid and quadricuspid aortic valve diagnosed in our Center. Clinical Cases Case 1. A 23-year-old asymptomatic male was admitted to our Hospital because of the necessity of bone marrow transplantation for Hodgkin lymphoma. He had a previous diagnosis of bicuspid aortic valve and presented a 5/6 mid-systolic harsh murmur, heard best at the right upper sternal border and radiating to the neck. ECG showed sinus rhythm with left ventricular hypertrophy. BNP was in normal range (31 pg/ml). At trans-thoracic echocardiography, there was severe aortic stenosis [peak/mean gradient of 100/67 mmHg with an aortic valve area of 1.04 cm2 (0.54 cm2/m2); V max was 5 m/s] without regurgitation and dilation of the ascending aorta (39 mm), however the morphology of the aortic valve remained undefined. Left ventricle showed hypertrophy (maximum wall thickness = 13 mm) with normal volumes and systolic function. Thus, the patient underwent to 3D-Transesophageal echocardiography, which demonstrated unicuspid aortic valve with a lone commissure between L-NC and anterior calcification. After multidisciplinary discussion, the patient underwent close follow-up and aortic valve replacement was planned after the bone marrow transplantation. Case 2. A 21-year-old male was referred by general practitioner to our outpatient clinic for palpitations. Cardiovascular physical examination and ECG were normal with no evidence of arrhyhtmia or cardiac murmurs. Transthoracic echocardiography revealed central mild aortic valve regurgitation in a suspected quadricuspid aortic valve (i.e., an X-shaped commissure pattern during diastole and a rectangular appearance during systole in the parasternal short-axis view). Left ventricular size and function and ascending aorta dimensions were normal. There was no associated congenital cardiovascular abnormality. 3D-Transesophageal echocardiography confirmed the evidence of a quadricuspid aortic valve. The cusps appeared to be of different size: two equal larger cusps and two equal smaller cusps (Type C, Hurwitz and Robert's classification), thin and mobile. The patient was advised to echocardiographic follow-up at intervals of 12 months. Conclusions We describe two cases of aortic valve congenital anomalies in two coetaneous patients with completely different impacts on hemodynamics. Severe aortic stenosis complicated unicuspid aortic valve whereas quadricuspid aortic valve was associated with mild aortic regurgitation. 3D-Transesophageal echocardiography was essential for accurate morphological characterization of the aortic valves.

Cardiac geometry, as assessed by cardiac magnetic resonance, can differentiate subtypes of chronic thromboembolic pulmonary vascular disease.

Ventricular septal flattening reflects RV pressure overload in pulmonary arterial hypertension. Eccentricity index (EI) and pulmonary artery distensibility (PAD) correlate with pulmonary artery pressure. We assessed the utility of these using cardiac magnetic resonance (CMR) to assess for pulmonary hypertension (PH) in patients with chronic thromboembolic disease. This may allow non-invasive differentiation between patients who have chronic thromboembolic pulmonary hypertension (CTEPH) and those with pulmonary vascular obstructions without PH at rest, known as chronic thromboembolic pulmonary disease (CTEPD). Twenty patients without resting pulmonary hypertension, including ten with chronic thromboembolic disease, and thirty patients with CTEPH were identified from a database at the Scottish Pulmonary Vascular Unit. CMR and right heart catheter had been performed within 96 h of each other. Short-axis views at the level of papillary muscles were used to assess the EI at end-systole and diastole. Pulmonary artery distensibility was calculated using velocity-encoded images attained perpendicular to the main trunk. Eccentricity index at end-systole and end-diastole were higher in CTEPH compared to controls (1.3 ± 0.5 vs. 1.0 ± 0.01; p ≤ 0.01 and (1.22 ± 0.2 vs. 0.98 ± 0.01; p ≤ 0.01, respectively) and compared to those with CTED. PAD was significantly lower in CTEPH compared to controls (0.13 ± 0.1 vs. 0.46 ± 0.23; p ≤ 0.01) and compared to CTED. End-systolic EI and end-diastolic EI correlated with pulmonary vascular hemodynamic indices and exercise variables, including mean pulmonary arterial pressure (R0.74 and 0.75, respectively), cardiac output (R-value -0.4 and -0.4, respectively) NTproBNP (R-value 0.3 and 0.3, respectively) and 6-min walk distance (R-value -0.7 and -0.8 respectively). Pulmonary artery distensibility also correlated with 6-min walk distance (R-value 0.8). Eccentricity index and pulmonary artery distensibility can detect the presence of pulmonary hypertension in chronic thromboembolic disease and differentiate between CTEPH and CTED subgroups. These measures support the use of non-invasive tests including CMR for the detection pulmonary hypertension and may reduce the requirement for right heart catheterization.

ECHO ROUND: THREE DIMENSIONAL TRIMMING, THE FREE ANGLE ALTERNATIVE FOR MITRAL AND AORTIC VALVE VITIUM ASSESSMENT.

Three-dimensional (3D) Technology provides real time dynamic assessment and allows for multiplanar reconstruction (MPR) for the different cardiac structures. However, it is much more demanding regarding the Echo device specification, and operator experience in both loop acquisition, enhancement and of course interpretation. Trimming function is one of the post-acquisition software tools, which can be used in step-by-step assessment of the Mitral valve (MV) and aortic valve (AV) vitrium. It didn't overcome the required experience required for the interpretation of 3D images. But when systematically done, it makes it more objective and allows for assessment of the coaptation line along the valve leaflets, even in cases where it is impossible to assess in 2D as between non-coronary and left coronary AV cusps. The loops in this poster were acquired with the Philips Affinity 70 and the X7-2T transoesophageal matrix array transducer. The basic requirement of the 3D loop acquisition is guided by the published recommendation as it is and when possible multibeat acquisition is used.1. In MV Our examination started in Midesophageal Intercommisural View with 3D Zoom function. We rotated the acquired loop to obtain the surgical view of the MV with the Aorta at 12 O'clock (Figure 1, Step 1). At this point we rotated the aorta to be positioned at 9 O'clock. (Figure 1 Step 2). Then, using the track ball, we rotated the 3D picture 90 degrees in the vertical axis to be facing the lateral annulus of the MV (Figure 1, Step 3) . Starting from this view, using the face Trimming function (figure 1 Step 4) we have adjusted the trimming level going deeper all through the MV from lateral to medial, examining the coaptation line all through all parts of the leaflets. What also helped to delineate the leaflets was to add more gain (in controversy to what is normally done to improve the 3D Image). For orientation, we recommend rotating the 3D loop back to surgical view to localize the trimming level. Color Flow Examination normally requires a multibeat acquisition to get a reasonable frame rate. We also trimmed from lateral to medial till we could see the Regurgitation Jet. (Figure 3) For AV we started with the Midesophageral AV short axis view and using loop was acquired using the 3D zoom function (Figure 4). Using the same technique we have adjusted the trimming line to go through the coaptation line needed to be examined between Non coronary cusp (NCC) – Right coronary cusp (RCC), RCC- Left coronary cusp (LCC) and NCC-LCC . (figure 5) .In each level we used the track ball to rotate the 3D image to get an inface view where we could see the coaptation. We could also measure coaptation height, coaptation length and identify single leaflet pathology. <b>Conclusion:</b> In contrast to 2D images the Trimming function allows a free angle generation of 2D images for angles difficult or sometimes impossible to be obtained with normal 2D cutting or even biplane.

Right Ventricular Segmental Rotation and Torsion in Normal Subjects on 2D Speckle Tracking Echocardiography

Background/Aims: Little is known about the complex anatomy of right ventricular (RV) torsion in the general population. This study was designed to assess RV’s global and segmental torsional motion in subjects without cardiac pathologies.Methods: We used the Vivid 7 ultrasound system (GE Healthcare, Chicago, IL, USA) to acquire parasternal short-axis views of the RV at the basal and apical levels, and analyzed global and segmental torsion using a 2D speckle tracking algorithm in EchoPAC workstation (GE Healthcare, Wauwatosa, WI, USA).Results: Forty-eight individuals (44 ± 17 years, 54% male) were included, with either normal left ventricular diastolic function (group I, n = 40) or grade I diastolic dysfunction (group II, n = 8). Group I showed global peak systolic torsion of 9.0 ± 6.6 degrees with higher segmental torsion in the mid-interventricular septum (IVS) than in the anterior walls (&lt;i&gt;p&lt;/i&gt; = 0.001). Global RV torsion showed a very strong positive correlation with apical rotation (r = 0.91, &lt;i&gt;p&lt;/i&gt; &lt; 0.001). Group I exhibited higher segmental torsion in the anterior-IVS and mid-IVS walls than group II (9.8 ± 7.1 vs. 3.5 ± 9.6 degrees, &lt;i&gt;p&lt;/i&gt; = 0.036; 10.4 ± 9.1 vs. 2.4 ± 12.3 degrees, &lt;i&gt;p&lt;/i&gt; = 0.038, respectively).Conclusions: Analysis of RV segmental torsion was feasible using a 2D speckle tracking algorithm. Apical rotation can be used as a simplified index of global RV torsion. Further studies are needed to evaluate the clinical impact of RV torsion in various pathologies.

Collapsed Woman With a D-Shaped Left Ventricle on Echocardiogram

A 45-year-old woman presented to the emergency department with unwitnessed out-of-hospital cardiac arrest with asystole rhythm. After intubation, transesophageal echocardiography was performed to search for possible etiologies of cardiac arrest. It showed a D-shaped left ventricle at the midventricular level in the transgastric short-axis view (Figure A and Video, available at http://www.annemergmed.com). After the return of spontaneous circulation, transesophageal echocardiography revealed the resolution of the D-shaped left ventricle (Figure B). Dilated right ventricle because of cardiac arrest. The right ventricle to left ventricle ratio was described as an echocardiographic sign suggesting pulmonary embolism with high specificity in previous studies.1Fields J.M. Davis J. Girson L. et al.Transthoracic echocardiography for diagnosing pulmonary embolism: a systematic review and meta-analysis.J Am Soc Echocardiogr. 2017; 30: 714-723.e4Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In our case, right ventricle dilation with septal flattening was also observed during resuscitation, which returned to normal size after the return of spontaneous circulation. In Aagaard's porcine studies,2Aagaard R. Caap P. Hansson N.C. et al.Detection of pulmonary embolism during cardiac arrest—ultrasonographic findings should be interpreted with caution.Crit Care Med. 2017; 45: e695-e702Crossref PubMed Scopus (27) Google Scholar,3Aagaard R. Granfeldt A. Bøtker M.T. et al.The right ventricle is dilated during resuscitation from cardiac arrest caused by hypovolemia: a porcine ultrasound study.Crit Care Med. 2017; 45: e963-e970Crossref PubMed Scopus (32) Google Scholar the right ventricle size showed no correlation with the causes of arrest. The right ventricle dilation might be inherent to cardiac arrest. Our case supported Aagaard’s studies; therefore, the dilated right ventricle noted on the echocardiography during resuscitation must be interpreted cautiously. Other differential diagnoses should be considered if the dilated right ventricle resolves after the return of spontaneous circulation. In patients with cardiac arrest, thrombus visualized in the proximal pulmonary arteries or right heart might be a more specific sign to diagnose pulmonary embolism and guide further treatment, such as thrombolytic therapy.4Konstantinides S.V. Meyer G. Becattini C. et al.2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J. 2020; 41: 543-603Crossref PubMed Scopus (1340) Google Scholar Gastric ulcer perforation was diagnosed following the return of spontaneous circulation by computed tomography. Gastrorrhaphy and drainage of intra-abdominal abscess were done; however, the patient died the next day because of a profound septic shock. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0ODMwZGY4ZmNmZjg3MWZkNjRiYzVkNTgyMjQ1YTNhNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTg5Mzc1fQ.GE5j2RbdtAaHLdnx_AuVeAXfSftnIEpj1OAn9NZU9Stpu06w5LMVtZlgBhaB1tMFs6TOjMwr5LfsP17MhOD7AgBQr4O2BAy1vl0OVBHuhL5TuNK8RFAIVShVmQL_BYFiB4Py1xh8kiU5JsL9kuInpRDAEX4P1ANaxTL9CyTD4X3O9sFEHJLh6LgERT2fq6XjhXu3qODqLCmCDR5S7EOiP8HuU5Mt_PONO5bLGStTYYHOK1vIP7OlT_nLlacBrdeUxJqIHmLdtMZCEkZLFAPedhLGI0Tok-ncrbC-qlUnk1JI2PIYwPtgdKEJrxh6SHIK4D0haEmqAqE7Fbj6EggPDw Download .mp4 (2.92 MB) Help with .mp4 files VideoThe transesophageal echocardiography showing a D-shaped left ventricle at the midventricular level in the transgastric short-axis view during resuscitation, which turned back to a normal shape after the return of spontaneous circulation was achieved.

Balanced Steady-State Free Precession Cine MR Imaging in the Presence of Cardiac Devices: Value of Interleaved Radial Linear Combination Acquisition With Partial Dephasing.

Balanced steady-state free precession (bSSFP) is important in cardiac MRI but suffers from off-resonance artifacts. The interpretation-limiting artifacts in patients with cardiac implants remain an unsolved issue. To develop an interleaved radial linear combination bSSFP (lcSSFP) method with partial dephasing (PD) for improved cardiac cine imaging when implanted cardiovascular devices are present. Prospective. Flow phantom adjacent to a pacemaker and 10 healthy volunteers (mean age ± standard deviation: 31.9 ± 2.9 years, 4 females) with a cardioverter-defibrillator (ICD) positioned extracorporeally at the left chest in the prepectoral region. A 3-T, 1) Cartesian bSSFP, 2) Cartesian gradient echo (GRE), 3) Cartesian lcSSFP, and 4) radial lcSSFP cine sequences. Flow artifacts mitigation using PD was validated with phantom experiments. Undersampled radial lcSSFP with interleaving across phase-cyclings and cardiac phases (RLC-SSFP), combined with PD, was then employed for achieving improved quality of cine images from left ventricular short-axis view. The image quality in the presence of cardiac devices was qualitatively assessed by three independent raters (1=worst, 5=best), regarding five criteria (banding artifacts, streak artifacts, flow artifacts, cavity visibility, and overall image quality). Wilcoxon rank-sum test for the five criteria between Cartesian bSSFP cine and RLC-SSFP with PD. Fleiss kappa test for inter-reader agreement. A P value < 0.05 was considered statistically significant. Based on simulations and phantom experiments, 60 projections per phase cycling and 1/6 PD were chosen. The in vivo experiments demonstrated significantly reduced banding artifacts (4.8 ± 0.4 vs. 2.7 ± 0.7), fewer streak artifacts (3.7 ± 0.6 vs. 2.6 ± 0.7) and flow artifacts (4.4 ± 0.4 vs. 3.7 ± 0.6), therefore improved cavity visibility (4.1 ± 0.4 vs. 2.9 ± 0.9) and overall quality (4.0 ± 0.4 vs. 2.7 ± 0.7). RLC-SSFP method with PD may improve cine image quality in subjects with cardiac devices. 2. Stage 1.

Abstract 14138: “RAC”ing up the Coronaries: An Underrecognized Echocardiographic Sign

Background: Both the retro-aortic anomalous coronary (RAC) and bleb signs are underrecognized echocardiographic findings suggestive of an anomalous left circumflex (LCx) coursing posterior to the aortic root. We present a patient in whom these echocardiographic signs were identified and confirmed on additional imaging. Case Presentation: A 77-year-old male presented with heart failure secondary to severe MR. In the apical 4 chamber (A4C) view, tilting anterior demonstrated the RAC sign, a highly echogenic tubular structure in the retro-aortic region above the mitral valve (panel A). In the parasternal long-axis view, the bleb sign, a round structure next to the aorto-mitral curtain, was identified (panel B). The RAC sign was also seen in the short-axis (SAX) as a tunnel-shaped structure behind the aortic root. This structure also represents an orthogonal view of the “bleb sign” (panel C). An anomalous LCx was suspected and was confirmed on both CTA and coronary angiography (panel D). The patient underwent successful mitral valve replacement. Discussion: The most common coronary anomaly is a LCx artery arising from the right sinus of Valsalva. Traditionally, either coronary angiography or CTA, has been required for diagnosis; however, these tests are expensive and invasive. The bleb and RAC signs must be differentiated from other more common echocardiographic findings. In the A4C view, the RAC sign can be mistaken for the coronary sinus, which is typically a more posterior structure, or for calcifications of the aortic valve, which would move with the valve and would not have internal anechoic components. The bleb sign can be differentiated from an abscess of the mitral-aortic fibrosa by identifying the tubular retro-aortic appearance of the structure in the SAX view. Conclusion: The RAC and bleb signs offer a noninvasive means identifying an anomalous LCx; however, they must be differentiated from other cardiac structures which can mimic their appearance.

IFT-Net: Interactive Fusion Transformer Network for Quantitative Analysis of Pediatric Echocardiography.

The task of automatic segmentation and measurement of key anatomical structures in echocardiography is critical for subsequent extraction of clinical parameters. However, the influence of boundary blur, speckle noise, and other factors increase the difficulty of fully automatically segmenting 2D ultrasound images. The previous research has addressed this challenge using convolutional neural networks (CNN), which fails to consider global contextual information and long-range dependency. To further improve the quantitative analysis of pediatric echocardiography, this paper proposes an interactive fusion transformer network (IFT-Net) for quantitative analysis of pediatric echocardiography, which achieves the bidirectional fusion between local features and global context information by constructing interactive learning between the convolution branch and the transformer branch. First, we construct a dual-attention pyramid transformer (DPT) branch to model the long-range dependency from spatial and channels and enhance the learning of global context information. Second, we design a bidirectional interactive fusion (BIF) unit that fuses the local and global features interactively, maximizes their preservation and refines the segmentation. Finally, we measure the clinical anatomical parameters through key point positioning. Based on the parasternal short-axis (PSAX) view of the heart base from pediatric echocardiography, we segment and quantify the right ventricular outflow tract (RVOT) and aorta (AO) with promising results, indicating the potential clinical application. The code is publicly available at: https://github.com/Zhaocheng1/IFT-Net.

Measuring Average Supraspinatus Tendon Thickness on Musculoskeletal Ultrasound: Variation in Young Adults

Background: The human shoulder is one of the most mobile joints of the body but it has less stability as compared to the hip joint which is also a ball and socket joint. Aim: To measure average supraspinatus tendon thickness in young adults, and compare the tendon thickness between genders by using musculoskeletal ultrasound. Study design: Cross sectional study. Methodology: A total of 128 healthy young adults were screened for shoulder pathology using Apley scratch test, Empty Can and Full Can test. The measurements were taken in Modified Crass Short Axis View of Supraspinatus Tendon at 5mm, 10mm and 15mm from Bicep Long Head Tendon and Modified Crass Long Axis View of Supraspinatus Tendon at 5mm, 7mm and 10mm from the highest point of humerus. Data was evaluated by using SPSS version 23. All qualitative data was presented in frequency form and quantitative data was in the form of mean ± SD. Results: There was a significant difference in tendon thickness between males and females. In the long axis view males had thicker tendon as compared to females at 5mm and 7mm in the right side whereas in the left side there was difference at 5mm, 7mm and 10mm from the highest point on the humerus. Within gender comparison showed significant difference in tendon thickness measured in short axis as significant tendon thickness difference measured at 5mm, 7mm and 10mm from highest point of humerus. Conclusion: It was concluded that supraspinatus tendon thickness differed significantly in young males and females. Keywords: Musculoskeletal Ultrasound, Supraspinatus Tendon Thickness, Young Adults, Body Mass Index and Rotator Cuff.

Infective Endocarditis Caused by Granulicatella elegans in a Child With Patent Ductus Arteriosus.

To the editors: Infective endocarditis (IE) is an inflammatory process of infectious origin that affects cardiovascular structures. The term endarteritis is currently included in the definition of infective endocarditis. Granulicatella elegans is a rare cause of infective endocarditis, which has a subacute presentation of the disease, with nonspecific symptoms and mild elevation of inflammatory biomarkers. It is associated with a high-mortality rate in adults.1 In the pediatric age group, there are 3 cases of IE described by Granulicatella spp., associated with congenital heart disease: 1 with pulmonary atresia with intact interventricular septum and mild Ebstein’s malformation already operated,2 another one with Shone’s syndrome and the last one with infundibular pulmonary stenosis.1 Our case represents the fourth case worldwide with IE caused by Granulicatella spp., in congenital heart disease, and the first with patent ductus arteriosus (PDA). We report an 8-year-old female patient with a history of PDA was diagnosed at another hospital at 3 years of age. She was referred from another hospital with a 7-month history of fever, predominantly during the evening, between 38.4°C and 38.6°C. On admission hyperdynamic precordium with thrill, normal S2, left infraclavicular continuous murmur grade 4/6, slightly grainy sound, calling attention to a metallized acoustic component and wide pulses. Three blood cultures tested positive after 48 hours. Gram staining of the blood culture revealed Gram-positive cocci, that were, nonsporulating in pairs and short chains and, pleomorphic (Fig. 1A). Blood cultures were identified with Granulicatella elegans nutritionally variant streptococci using a commercial kit MALDI Sepsityper (Bruker Daltonics). Little growth on sheep-blood agar in a microaerophilic atmosphere after 72 hours.FIGURE 1.: A. Gram staining showing Gram-positive cocci, nonsporulating in pairs and, short chains, pleomorphic. B, (day 30) TTE. Parasternal 2D short axis view and color Doppler showing PDA with left to right shunt and hyperechogenic mass (green arrow) in the PA following the flow of the ductus. PA, pulmonary artery; PDA, patent ductus arteriosus; TTE, transthoracic echocardiogram.Vegetations were not found on the transthoracic echocardiogram (TTE) at admission, but after 30 days reveled; image suggestive of vegetation attached the pulmonary trunk (13 mm × 3 mm) (Fig. 1B). After completing 40 days of ceftriaxone, the vegetation was removed percutaneously, on the 58th day, the PDA was closed with Amplatzer ADO 8/6. Despite advances in diagnosis and treatment, infective endocarditis in the 21st century can be a life-threatening disease with high morbidity and mortality.1 Cyanogenic congenital heart disease, left heart lesions and atrioventricular defects are associated with an increased risk of IE in childhood.3 In children, the most frequent microorganism in subacute IE is Streptococcus viridans group4; however, in the second group nutritionally variant Streptococcus species (NVS) have been identified as etiological agents responsible for 5% of the cases with bacteriologic diagnosis.5 Physicians should suspect subacute IE in patients presenting with intermittent fever of prolonged evolution, constitutional symptoms, and changes in auscultatory phenomena in the context of children with congenital heart disease, despite having negative initial blood culture and absence of initial IE findings on echocardiogram. Granulicatella spp., IE has a subacute presentation with a mild increase in inflammatory biomarkers, and its morbidity and mortality can be significant. The modified Duke criteria are of great value; however, in some patients with subacute IE the diagnosis can be missed, therefore, the clinical features should be considered when a patient has a fever of unknown origin.

Transesophageal echocardiographic imaging of the coronary sinus: a retrospective analysis of mid-esophageal views and a novel transgastric view

BackgroundTransesophageal echocardiographic imaging plays an important role in assessing coronary sinus anatomy prior to placement of a retrograde cardioplegia cannula. The coronary sinus can be imaged in the long axis by advancing the TEE probe from the mid-esophageal 4-chamber view or using a modified mid-esophageal bicaval view, while a short axis view can be obtained in the mid-esophageal 2-chamber view. While use of a transgastric view is only briefly mentioned in the literature as an alternative to mid-esophageal views, the authors commonly include it in our comprehensive transesophageal echocardiographic exam of the coronary sinus. This study examines the various imaging strategies. We hypothesize that the transgastric view offers comparable coronary sinus imaging to the mid-esophageal views.MethodsAfter approval by our institutional review board, the intraoperative transesophageal echocardiographic exams for 50 consecutive elective cardiac surgical patients with a comprehensive echocardiographic assessment of the coronary sinus were retrospectively reviewed and analyzed to evaluate imaging of the coronary sinus in the various views. For each view, we noted and recorded if the coronary sinus and coronary sinus cannula were visualized. Statistical analysis required pairwise comparisons between each of the 4 views. P values were calculated using McNemar’s Exact test.ResultsBoth the coronary sinus and coronary sinus cannula were visualized a majority of the time for each view. There was no statistically significant difference between each view in its ability to visualize the coronary sinus, nor was there a statistically significant difference between each view in its ability to visualize the coronary sinus cannula.ConclusionsUse of a transgastric window provides the echocardiographer with an effective alternate modality for imaging the coronary sinus when mid-esophageal views are limited.

Improving echographic monitoring of hemodynamics in critically ill patients: Validation of right cardiac output measurements through the modified subcostal window

ObjectiveWe aimed to assess the usefulness of using the right ventricle outflow tract (RVOT) velocity-time integral (VTI) for echocardiographic monitoring of cardiac output compared to the gold standard, the VTI along the left ventricle outflow tract (LVOT). DesignProspective observational study. SettingA tertiary intensive care unit. Patients100 consecutive patients. Interventions: echocardiographic monitoring in critically ill patients. Main variables of interestWe used intraclass correlation coefficients (ICC) to compare echocardiographic measurements of LVOT VTI through apical window with RVOT VTI through the parasternal and modified subcostal windows and to assess interobserver reproducibility. Preplanned post hoc analyses compared the ICC between ventilated and nonventilated patients. ResultsAt the time of echocardiography, 44 (44%) patients were mechanically ventilated and 28 (28%) were receiving vasoactive drugs. Good-quality measurements were obtained through the parasternal short-axis and/or apical views in 81 (81%) patients and in 100 (100%) patients through the subcostal window. Consistency with LVOT VTI was moderate for RVOT VTI measured from the modified subcostal view (ICC 0.727; 95%CI: 0.62–0.808) and for RVOT VTI measured from the transthoracic view (0.715; 95%CI: 0.59–0.807). ConclusionsMeasurements of RVOT VTI are moderately consistent with measurements of LVOT VTI. Adding the modified subcostal window allows monitoring RVOT VTI in all the patients of this selected cohort, even those under mechanical ventilation.

Medical student medium-term skill retention following cardiac point-of-care ultrasound training based on the American Society of Echocardiography curriculum framework

BackgroundNo studies have demonstrated medium- or long-term skill retention of cardiac point-of-care ultrasound (POCUS) curriculum for medical student. Based on the American Society of Echocardiography (ASE) curriculum framework, we developed a blended-learning cardiac POCUS curriculum with competency evaluation. The objective of this study was to investigate the curriculum impact on image acquisition skill retention 8 weeks after initial training.MethodsThis study was a prospective, pre-post education intervention study for first- and second-year medical students, with blinded outcome assessment. The curriculum included a pre-training ASE online module and healthy volunteer hands-on training to obtain 5 views: parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical 4-chamber (A4C), subcostal 4-chamber (S4C), and subcostal inferior vena cava (SIVC) views. Students took 5-view image acquisition skill tests at pre-, immediate post-, and 8-week post-training, using a healthy volunteer. Three blinded assessors rated the image quality using a validated 10-point maximum scoring system. Students used a hand-held ultrasound probe (Butterfly iQ).ResultsFifty-four students completed hands-on training, and pre- and immediate post-training skill tests. Twenty-seven students completed 8-week post-training skill tests. Skill test score improvement between pre- and 8-week post-training was 2.11 points (95% CI, 1.22–3.00; effect size, 1.13).ConclusionThe cardiac POCUS curriculum demonstrated medium-term skill retention. The curriculum was sufficient for S4C and SIVC skill retention, but inadequate for PLAX, PSAX, and A4C. Therefore, instructional design modifications or re-training for PLAX, PSAX, and A4C are needed to make the curriculum more effective for clinically relevant skill retention.

Association of heart failure and liver T1 mapping in cardiac magnetic resonance imaging

Abstract Background Heart failure culminates in liver congestion. As the liver can be assessed by cardiac magnetic resonance T1 mapping sequences, it represents a promising imaging biomarker for heart failure. Objectives To evaluate the association between heart failure and magnetic resonance liver T1 mapping, as a non-invasive imaging surrogate of liver congestion. Methods Patients with cardiac magnetic resonance including T1 mapping sequences on a single 1.5T scanner were consecutively included between 01/2017 and 12/2019. Liver T1 was measured in the left lobe, right lobe and caudate lobe on short axis view and in the liver dome on four chamber view. Echocardiographic and laboratory parameters were analyzed within 90 days of the cardiac magnetic resonance exam. Left ventricular filling pressures were assessed according to the European Association of Cardiovascular Imaging guidelines [1]. Liver T1 and echocardiographic parameters were compared between patients with and without elevated NT-proBNP levels (&amp;gt;125 pg/ml) using a Mann-Whitney U test. A multivariate logistic regression model was used to correct for age, sex, body mass index, left ventricular ejection fraction and the presence of atrial fibrillation. Results A total of 397 patients were included (median age 56, 127 females), of whom 138 patients (35%) presented with elevated NT-proBNP levels. Patients with elevated NT-proBNP levels had a larger indexed end-diastolic left ventricular volume (92 vs. 81 ml/m2, p&amp;lt;0.001), lower left ventricular ejection fraction (60 vs. 50%, p&amp;lt;0.001) and a higher E/E' ratio (11 vs. 8, p&amp;lt;0.001). Liver T1 was higher in patients with elevated NT-proBNP in the right liver lobe (670 vs. 596 ms, p&amp;lt;0.001) and the caudate lobe (664 vs. 598 ms, p&amp;lt;0.001), but not in the left liver lobe (571 vs. 568 ms, p=0.068) and in the liver dome (590 vs. 560 ms, p=0.1). Echocardiographic evaluation showed similar results with significant difference in T1 times between patients with elevated and non-elevated left ventricular filling pressures in caudate and right liver lobe. Liver T1 retained its predictive value when corrected for age, left ventricular ejection fraction and the presence of atrial fibrillation, when measured in the caudate lobe (adjusted odds ratio 1.013, 95% confidence interval 1.004–1.023, p=0.005) and in the right lobe (adjusted odds ratio 1.012, 95% confidence interval 1.003–1.021, p=0.009). Conclusions Elevated liver T1 in cardiac magnetic resonance imaging is associated with heart failure and represents an independent non-invasive imaging surrogate for liver congestion. Funding Acknowledgement Type of funding sources: None.