Specificity Of Transthoracic Echocardiography Research Articles

Abstract 14663: Machine Learning to Detect Pulmonary Hypertension at Point-of-Care

Introduction: Pulmonary hypertension (PH) is defined by mean pulmonary arterial pressure (mPAP) of ≥ 21 mmHg or ≥ 25 mmHg by right heart catheterization (RHC), (2022 and 2015 ERS/ESC guidelines). Based on a recent meta-analysis, the sensitivity and specificity of transthoracic echocardiography (TTE) is 83% and 72% in the 59% of patients where tricuspid regurgitant velocity (TRV) is available. Research Question: Can we develop a point of care method to detect PH, based on cardiac orthogonal voltage gradient (OVG) signals and photoplethysmographic (PPG) signals? Aim: Using OVG and PPG signals from subjects evaluated with RHC or TTE (independent of TRV), we built a machine learned (ML) model that can identify subjects with PH with high accuracy. Methods: 3298 features from PPG and OVG signals were reduced to 216 via univariate testing. ElasticNet and Random Forest models were developed using a coarse grid-search based on 5-fold cross-validation followed by a narrow search when the two algorithms were ensembled, performed on a naive set of subjects with confirmed PH (N=327, mPAP ≥ 21 mmHg; N=252, mPAP ≥ 25 mmHg) vs. subjects with high negative predictive value for absence of PH, i.e., meeting the 2022 ERS/ESC TTE guideline criteria for “Low Probability” of PH adjudicated by a core lab (N=204). The model prediction for the selected hyperparameters was generated for every subject using out-of-fold prediction. Results: Table 1 demonstrates strong performance across gender and PH subgroups. AUC for all PH/Pre-capillary PH based on the 2015 ERS/ESC guidelines is 0.92/0.95, sensitivity 90%/95% and specificity 75%/75%. Using the updated 2022 guidelines, AUC for all PH/Pre-capillary PH is 0.90/0.92, sensitivity 90%/93% and specificity 69%/69%. Conclusion: Clinically relevant performance using a ML algorithm based on non-invasive signals collected at point-of-care is achievable in the identification of PH (and specifically, Pre-capillary PH), not limited by availability of TRV.

Correction to: Sensitivity and Specificity of Transthoracic Echocardiography in Diagnosing the Presence of the Anomalous Origin of Left Circumflex Coronary Artery From the Right Sinus of Valsalva in an Adult Population.

Correction to: Sensitivity and Specificity of Transthoracic Echocardiography in Diagnosing the Presence of the Anomalous Origin of Left Circumflex Coronary Artery From the Right Sinus of Valsalva in an Adult Population.

Abstract 15255: Clinical Risk Factors for Infective Endocarditis in Patients With Staphylococcus Aureus Bacteremia and the Diagnostic Utility of Transesophageal Echocardiogram

Background: Approximately 25% of patients with staphylococcus aureus bacteremia (SAB) develop infective endocarditis (IE), which has a consequent mortality of 46%. Current guidelines recommend routine transthoracic echocardiography (TTE) for patients with SAB; transesophageal echocardiogram (TEE) is reserved for those patients in whom initial TTE is negative and clinical suspicion for IE remains high. We sought to elucidate high risk features of SAB associated with the development of IE that warrant a TEE after a negative TTE. Methods: This retrospective study included 213 patients who were diagnosed with SAB at the University of New Mexico Hospital between 2010-2020. A pre-determined list of clinical risk factors along with TTE and TEE status was extracted from the electronic medical record (Table 1). Our primary outcome was the development of IE in patients with SAB. Multivariate logistic regression analysis was used to identify clinical risk factors for IE. Sensitivity and specificity of TTE and TEE was also calculated (Table 1). Results: Out of 213 patients with SAB, 68 patients met diagnostic criteria for infectious endocarditis. Most patients (n=209) underwent TTE and 117 patients underwent subsequent TEE. Initial TTE was diagnostic in 42 patients with a sensitivity of 63% and specificity of 94%; 45 patients had a diagnostic TEE with a sensitivity of 83% and specificity of 98%. Multivariate analysis showed significantly increased risk of IE in patients who had a permanent pacemaker (aOR 32.3, CI 5.23 - 281, p<0.001) or a persistent fever (aOR 6.97, CI 2.42 - 21.0, P<0.001). Conclusions: The routine use of TEE in patients with SAB for the diagnosis of IE may not be necessary and introduces unnecessary procedural risk. Based on our analysis, we recommend that SAB patients with a permanent pacemaker (or other intracardiac prosthetic) or a persistent fever despite appropriate antibiotic therapy be screened with TEE when initial TTE is negative.

Comparison of non-triggered magnetic resonance imaging and echocardiography for the assessment of left atrial volume and morphology

BackgroundAdvanced atrial fibrillation (AF) patients have persistent AF, failed previous catheter ablation and/or an enlarged left atrium (LA), which is associated with a reduced success of AF ablation. Transthoracic echocardiography (TTE) and contrast enhanced magnetic resonance angiography (CE-MRA) are available to assess LA volume. However, it is unknown how these modalities relate in patients with advanced AF. We therefore compared the reproducibility of TTE and non-triggered CE-MRA in advanced AF patients and their ability to select patients with successful thoracoscopic AF ablation.MethodsTwo independent observers measured LA volumes on 65 TTE and CE-MRA exams of advanced AF patients prior to AF ablation. Patients were followed after AF ablation with rhythm monitoring every 3 months for 1 year to determine AF recurrence. Inter-modality, inter- and intra-observer variability were determined using intraclass correlation coefficients (ICC). Receiver-operating characteristic (ROC) analysis was performed to determine sensitivity and specificity of TTE and CE-MRA volume and CE-MRA dimensions to identify patients with AF recurrence during follow-up.ResultsLA enlargement ≥ 34 ml/m2 was present in 60% of the patients. CE-MRA and TTE demonstrated a good correlation for LA volume assessment (intraclass correlation, ICC = 0.86; p < 0.001) with larger volumes consistently measured by CE-MRA. Major discrepancies were mostly attributed to TTE acquisition. Craniocaudal enlargement discriminated patients with AF recurrence (AUC 0.67 [95% CI 0.55–0.85], p = 0.01).ConclusionsNon-triggered CE-MRA is a viable and reproducible 3D alternative for 2D TTE to assess LA volume in advanced AF patients. Craniocaudal enlargement was the only discriminator of AF recurrence after AF ablation.

Comparative Sensitivity of Transthoracic and Transesophageal Echocardiography in Diagnosis of Infective Endocarditis Among Veterans With Staphylococcus aureus Bacteremia.

Echocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial. We identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making. Of 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of 17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%). Patients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.

Echocardiography in Diagnosis and Management of Infective Endocarditis

capabilities of echocardiography and its broad use in routine every day clinical practice. In the evaluation of infective endocarditis echocardiography can detect vegetations on heart valves, cuspis rupture or perforation and perivalvular inflammatory process spreading. According to the Duke criteria echocardiographic finding is one of the main criteria for diagnosis of endocarditis. The positive echocardiographic findings include: vegetations, abscess, new onset of artificial valve dehiscence and new onset of valvular regurgitation [2]. We use echocardiography to detect changes of cardiac valves and to evaluate systolic and diastolic heart function. Vegetations can be found on native or artificial valves and on the pacemaker or implantable cardioverterdefibrillator (ICD) leads. Vegetations are detected in 42-86% of patients with IE by applying echocardiography. The comparison of the results between transoesophageal echocardiography (TOE) and transthoracic echocardiography (TTE) in the detection of vegetations shows better sensitivity of TOE (85-90%) than the sensitivity of TTE (60%). Specificity of TTE is 67%, and specificity of TOE is around 91-98%. 3D and 4D TOE have been used more commonly in the diagnostics in the last ten years. The sensitivity of this new methods in diagnosis of infective endocarditis is similar to 2D TOE, while its specificity is much higher (100%). However, sensitivity of TTE is much lower in detecting vegetations in patients with artificial valves, implanted pacemaker or implantable cardioverter-defibrillator. We can use the echocardiography to determine size, echogenity and mobility of vegetation. Based on this indicators it is possible to make a decision about surgical treatment, estimate the risk of embolic event and predict the clinical outcome [3]. The patients with vegetations that larger than 1,0 cm in diameter have significantly higher risk of embolic event (36%) than the patients with vegetations smaller than 1,0 cm (6%). According to the new Guidelines of European Society of Cardiology (ESC) for the management of infective endocarditis, it is important to perform TTE in each patient with suspicion of infective endocarditis. In all patients with artificial heart valve, pacemaker or cardioverter- defibrillator, it is indicated to perform TOE [5-7]. Further more, in cases of negative TTE in patients with high clinical suspicion of endocarditis, it is advisible to perform TOE as well [4]. About 15 % of patients with endocarditis have normal echocardiographic finding. Echocardiography may not detect vegetations in too early stage of disease or in case when vegetation caused an embolic event [8]. In some cases we may not detect vegetations due to significant preexistent lesions on valves, such as mitral valve prolapse, degenerative process or due to acustic shadows and reverberations caused by artificial valves. In case echocardiography assesment was made in very early stages of disease with negative examination but with high clinical suspicion of infective endocarditis, it is indicated to repeat the TTE and/or TOE within 5-7 days. Conclusion Early diagnosis, prompt and efficient therapy and detecting and dealing with the complications are the most important factors in achieving good outcome in endocarditis treatment. Echocardiography has important role in diagnosis of endocarditis, detection of complications, decision making regarding the surgical treatment and patients follow-up with great prognostic significance remarkably contributing to better outcome.

Diagnostic Accuracy of Transthoracic Echocardiography to Predict Fluid Responsiveness by Passive Leg Raising in the Critically Ill: A Meta-Analysis

Background: Hemodynamic instability is common in critical patients and not all patients respond to fluid challenge, so we need accurate and rapid hemodynamic techniques to help the clinicians to guide fluid treatment. Numerous hemodynamic techniques have been used to predict fluid responsiveness till now. Transthoracic echocardiography (TTE) appears to have the ability to predict fluid responsiveness, but there is no consensus on whether it can be used by passive leg raising (PLR). Methods: We performed a literature search using MEDLINE (source PubMed, from 1947), EMBASE (from 1974) and the Cochrane Database of Systematic Reviews for prospective studies with no restrictions. Pooled effect estimates were obtained by using random-effects meta-analysis. Results: 7 prospective studies involving 261 patients and 285 boluses were identified. The pooled sensitivity and specificity of TTE are 86% (79% - 91%) and 90% (83% - 94%), respectively. The summary receiver operating characteristic (sROC) curve shows an optimum joint sensitivity and specificity of 0.88, with area under the sROC curve (AUC) of 0.94. The result of diagnostic odds ratio (DOR) is 50.62 (95% confidence interval [CI]: 23.70 - 108.12). The results of positive likelihood ratio (+LR) and negative likelihood ratio (?LR) are 7.07 (95% CI: 4.39 - 11.38) and 0.19 (95% CI: 0.13 - 0.28), which indicated strong diagnostic evidence. Conclusions: TTE is a repeatable and reliable noninvasive tool to predict fluid responsiveness in the critically ill during PLR with good test performance. This meta-analysis brings evidence to employ well-trained clinician-echocardiographers to assess patients’ volume statue via TTE to benefit daily work in intensive care units (ICUs).

Diagnostic Value of Cardiac MRI in Comparison to Trans-Thoracic Echocardiography in Detection and Characterization of Cardiac Masses

Background: Cardiac masses are uncommon and encompass a spectrum of lesions with different histological features. Despite rarity, serious complications associated with these lesions render the need for a sensitive, specific, and accurate diagnostic tool which may lead to treatment options such as cardiac surgery as a major invasive intervention. Objectives: The purpose of this study was to compare accuracy and specificity of trans-thoracic echocardiography (TTE) and cardiac MRI (CMRI) as the two non-invasive diagnostic methods available. Patients and Methods: Thirty-eight patients who were suspected to have cardiac or pericardiac space occupying lesions on TTE were included in this study. CMRI protocols include steady cine imaging, HASTE and 3D-IR FLASH sequences after contrast (Gd-chelate) administration in first pass and delayed images added to common CMRI sequences (T1 and T2 TSE) Results: Of the 38 subjects, 27 (PPV, 68.4%) had findings in CMRI in favor of SOL (other studies were either normal or suggestive of other disorders such as cardiomyopathies). Of these, 18 were solid masses and 9 were either cystic mass lesions or clots. In view of CMRI findings and clinical indications, 20 patients underwent operation and for all of them the diagnosis of SOL lesions was confirmed (no false positive). On CMRI, 11 cardiac tumors had findings suggestive of malignancy, which was consistent with the histopathology results in 10 operated patients (specificity, 90.9% of tissue diagnosis). CMRI features in 7 patients were in favor of indeterminate or benign lesions with a PPV of 83.3% after histological comparison (6 masses were resected). Five lesions which were suspected of being neoplastic masses on TTE, turned out to be endocardial vegetations or thrombi on CMRI (PPV, 78%). In five patients who underwent CMRI for characterization of cystic lesion detected by TTE, findings of both modalities were almost consistent with each other with a superior precision in CMRI characterization. Invasion to adjacent organs or remote organs involvement was detected in 7 patients, completely compatible with intra-operational observations and/or further investigations (specificity, 100%). Conclusions: CMRI with specific sequences and multiplanar image is by far the most accurate non invasive modality in detection and evaluation of mass lesions in and around heart.

Diagnostic Value of Transthoracic Echocardiography for Patent Foramen Ovale: A Meta-analysis

As a non-invasive and convenient modality, transthoracic echocardiography (TTE) has been widely recommended for the diagnosis of patent foramen ovale (PFO). In this study our aim was to systematically review the diagnostic accuracy of TTE in detection of PFO. We conducted comprehensive searches in PubMed, Embase and the Cochrane Library to the end of September 1, 2012. Sixteen studies comprising 1831 patients were included in the meta-analysis. The quality of reported studies was modest. The summary sensitivity and specificity of TTE in diagnosis of PFO were 88% (95% confidence interval [CI], 79–94) and 97% (95% CI, 92–99), respectively. The positive likelihood ratio was 27.1 (95% CI, 11.2–65.1), and the negative likelihood ratio was 0.12 (95% CI, 0.07–0.22). The summary diagnostic odds ratio was 221 (95% CI, 95–518). Subgroup analyses suggested that age and initial disease may affect the accuracy of TTE in detection of PFO. The meta-analysis suggested that TTE is a test with high sensitivity and specificity in detection of PFO, but it may not be appropriate for screening for PFO in all patients, especially patients with a small right-left shunt.

Comparison of the Diagnostic Power of Transthoracic and Transesophageal Echocardiography to Detect Ruptured Chordae Tendineae

Preoperative information concerning the severity and etiology of MR is very important for selecting the most appropriate surgical strategy. Ruptured chordae tendineae (RCT) are one of the most important preoperative findings. We compared the diagnostic power of transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) to detect RCT in patients with MR. We studied 61 patients with MR (30 men, 31 women; mean age, 61 ± 12 years) who underwent mitral valve repair or replacement. Both TTE and TEE were performed before the operations, and the sensitivity and specificity of TTE and TEE to detect RCT were determined. In addition, other factors that influenced the detection of RCT by these two methods were investigated. At the time of an operation, RCT was confirmed in 39 of 61 cases. Transesophageal echocardiography had a higher sensitivity than TTE (74% versus 44%; P = 0.006) to detect RCT, although the specificity was not significantly different. In patients with a body mass index (BMI) > 22 (P = 0.023) or MR grade 4 (P = 0.026), TEE had a significantly higher diagnostic sensitivity than TTE, although there was no significant difference in patients with BMI < 22 or MR grade ≤ 3. In the lateral and medial segments of the mitral valve, TEE had a significantly higher diagnostic sensitivity to detect RCT than TTE (P = 0.0012), although there was no significant difference in the middle segments. There was no significant difference between TTE and TEE with respect to the sensitivity to detect RCT in myxomatous mitral valves. Although the sensitivity of TEE was higher than that of TTE to detect RCT, it was affected by BMI, MR grade, the RCT-presenting segments, and the etiology of MR.

Echocardiographic findings of tricuspid blood cyst mimicking bacterial endocarditis in a dairy cow

The most common endocardial disease in cattle is bacterial endocarditis. The diagnosis of the disease in living animals is mainly based on clinical findings and echocardiographic detection of an irregularly thickened valve. Despite its presumed good sensitivity, little is known on the specificity of transthoracic echocardiography with regards to endocarditis. This case report describes the echocardiographic findings in a dairy cow diagnosed with a chronic inflammatory process, liver and splenic abscesses and tricuspid valve blood cysts that can be mistaken for bacterial endocarditis, thus emphasizing the need to improve antemortem diagnostic tools for endocarditis in cattle.

Clinical Utility of New Real Time Three‐Dimensional Transthoracic Echocardiography in Assessment of Mitral Valve Prolapse

Noninvasive and accurate assessment of mitral valve anatomy has become integral in the presurgical evaluation of patients with mitral valve prolapse (MVP). Recently developed real time three-dimensional (RT3D) ultrasound allows online acquisition, rendering, and can provide accurate information on cardiac structures. We sought to evaluate the feasibility of RT3D for the assessment of MVP segments when compared with transesophageal echocardiography (TEE) and intraoperative findings. We examined 42 patients with MVP using RT3D, two-dimensional (2D) transthoracic echocardiography (TTE) and TEE. For RT3D analysis, cropping planes were used to slice the 3D volume on line to visualize the prolapsed segments of the mitral valve leaflets. The mitral valve was divided into six segments based on the American Society of Echocardiography's recommendations. Two experienced cardiologists evaluated echocardiographic images. Adequate RT3D images of the mitral valve were acquired in 40 out of 42 patients. The sensitivity and specificity of RT3D for defining prolapsed segments when compared with TEE were 95% and 99%, respectively (anterior leaflet: 96% and 99%, posterior leaflets: 93% and 100%, respectively). The sensitivity and specificity of TTE were 93% and 97%, respectively (anterior leaflet: 96% and 98%, posterior leaflets: 90% and 97%, respectively). Interobserver agreement for RT3D (Kappa 0.95, 95% confidence interval [CI] 0.91-1.00) was significantly greater than for TTE (Kappa 0.85, 95% CI 0.78-0.93) (P < 0.05). The elapsed time for completion of RT3D (14.4 +/- 2.8 min) was shorter than for TEE (26.4 +/- 4.7 min, P < 0.0001) and TTE (19.0 +/- 3.1 min, P< 0.0001). RT3D is fast, accurate, and highly reproducible for assessing MVP.

Location, size and morphological characteristics of left atrial thrombi as assessed by echocardiography in patients with rheumatic mitral valve disease.

This study aimed to assess the use of transthoracic and transoesophageal echocardiography in diagnosing the thrombi located in the left atrium and/or left atrial appendage in patients with rheumatic mitral valve disease, and to investigate the characteristics of thrombi in comparison to intraoperative findings. The study group was comprised of 474 patients who underwent transthoracic and transoesophageal echocardiography prior to mitral valve surgery. Location, thickness and morphological characteristics of thrombi were determined by transoesophageal echocardiography. Intraoperative assessment disclosed left atrial thrombi in 105 patients. Thickness of thrombi < or = 1cm, and thrombi confined to left atrial appendage were associated with false-negative results by transthoracic echocardiography. However, diameter and morphological characteristics of thrombi, left atrial and left atrial appendage size, and the presence of the spontaneous echo contrast were not associated with the diagnosis of thrombi by transthoracic echocardiography. For overall left atrial thrombi, sensitivity and specificity of transthoracic echocardiography were 32%, and 94%, respectively. Sensitivity and specificity of transoesophageal echocardiography for thrombi in the left atrial appendage were 98%, and 98%, for thrombi in the main left atrial cavity were 81%, and 99%, and for thrombi located in both left atrium and appendage cavities were 100%, and 100%, respectively. In patients with rheumatic mitral valve disease, detection of left atrial thrombi by transthoracic echocardiography seems to be determined by thickness and location of thrombi. The multilobed structure of the left atrial appendage and artifacts over posterior wall of the left atrium may still prevent precise diagnosis even with transoesophageal echocardiography.

Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients

PURPOSE: Echocardiography is advocated by some as a useful diagnostic test for patients with suspected pulmonary embolism (PE), but its diagnostic accuracy is unknown. The present study was undertaken to determine prospectively the sensitivity and specificity of transthoracic echocardiography in the diagnosis of PE. SUBJECTS AND METHODS: We examined 110 consecutive patients with suspected PE. The study protocol included assessment of clinical probability, echocardiography, and perfusion lung scanning. Pulmonary angiography was performed in all patients with abnormal scans. As echocardiographic criteria to diagnose acute PE, we used the presence of any two of the following: right ventricular (RV) hypokinesis, RV end-diastolic diameter >27 mm (without RV wall hypertrophy), or tricuspid regurgitation velocity >2.7 m/sec. Clinical estimates of PE served as pretest probabilities in calculating, after echocardiography, the posttest probabilities of PE. RESULTS: Pulmonary angiography confirmed PE in 43 (39%) of 110 patients. Echocardiographic diagnostic criteria for PE yielded a sensitivity of 56% and a specificity of 90%. For pretest probabilities of 10%, 50%, and 90%, the posttest probabilities of PE conditioned by a positive echocardiogram were 38%, 85%, and 98%, respectively. The posttest probabilities of PE conditioned by a negative echocardiogram were 5%, 33%, and 81%, respectively. CONCLUSIONS: In unselected patients with suspected PE, transthoracic echocardiography fails to identify some 50% of patients with angiographically proven PE. Although echocardiographic findings of RV strain, paired with a high clinical likelihood, support a diagnosis of PE, the transthoracic echocardiography has to have a better sensitivity to be used as a screening test to rule out PE.