Standard Transthoracic Echocardiography Research Articles

Diagnosis of hypertrophic cardiomyopathy by artificial intelligence using standard transthoracic echocardiography

Abstract Introduction Misdiagnosis of hypertrophic cardiomyopathy (HCM) is not uncommon among patients with left ventricular hypertrophy (LVH). Purpose We hypothesized that a convolutional neural network (CNN) could be trained to identify HCM patients among individuals with LVH using standard transthoracic echocardiography (TTE). Methods Echocardiographic reports of 121,767 unique patients linked to clinical data from the largest tertiary medical centre in the country (2007-2022) were reviewed. Patients with no septal hypertrophy were excluded. All HCM cases were retrieved from electronic medical records and were adjudicated by the authors. Data was then divided into 3 mutually exclusive cohorts: training (N=7,368), testing (N=2,456) and validation (2,456) cohorts. Deep learning models were used in order to train a model that identifies HCM patients. The model was based solely on parasternal long axis and apical four chamber views. Results Final study population included 12,281 patients who underwent a total of 27,242 echocardiography studies. There were 1535 (12%) patients with HCM. Mean age of study population was 72±14 and 7,943 (65%) were men. Overall, the model obtained 98.1% classification accuracy with an area under the curve of 0.851 in the independent test data (FIGURE) which could translate to sensitivity and specificity of 68% and 99%, respectively with positive and negative predictive values of 50% and 99%, respectively. Conclusions Applying artificial intelligence to the standard TTE can identify HCM patients with a reasonable accuracy. With further evaluation, this tool can be used to assist in HCM diagnosis.

Point-of-care screening for heart failure with reduced ejection fraction using simple pulse oximetry

Abstract Background More than 64 million patients with heart failure (HF) are burdened with poor quality of life, frequent hospitalizations, and high readmission rates. While HF with reduced ejection fraction (HFrEF) accounts for approximately half of these patients, there is currently no effective tool for performing cost-effective and reliable early-stage screening. For this purpose, we derived and cross-validated a machine learning (ML) based system capable of identifying HFrEF based on analysis of the photoplethysmographic (PPG) signal recorded by a simple pulse-oximeter. Methods Patients attending a routine ambulatory check-up at an outpatient clinic were included in the study. Left ventricular ejection fraction was determined by standard transthoracic echocardiography. Diagnosis of HF was based on the latest ESC recommendations for HF. PPG was measured using a standard oximeter modified to record raw PPG signal. Before processing, the quality of the measured PPG signal was assessed by signal quality indices to determine whether the quality of signal was sufficient for further analysis. In brief, the signal processing involved noise removal, filtering for specific frequencies, automatic artifact detection and identification of individual heartbeats, on which specific parts of the signal and signal characteristics, necessary for further analysis, were identified. Four different ML processing pipelines with different approaches to feature selection and class balancing were deployed, validated using the K-fold cross-validation and compared. Results A total of 371 patients were included in the study: 54 patients with HFrEF (mean age 66.87 ± 14.35, 74.07% male) and 317 patients with HFmrEF (4), HFpEF (42) or no history of HF (271) (mean age 54.12 ± 17.79, 51.73% male). From the 4 ML pipelines, LightGBM with SMOTE + Edited Nearest Neighbors balancing had the highest cross-validated predictive performance for detection of HFrEF (c-statistics 0.8, CI 0.69 – 0.89). Conclusions Our results suggest that HFrEF can be effectively screened using a simple pulse oximeter, thanks to ML signal analysis. This solution could be adapted to a simple, non-invasive, readily available, time-saving, and inexpensive point-of-care diagnostic tool for primary care. Early disease detection and referral to a cardiologist (or HF specialist) would have a positive impact on patient morbidity and mortality.Receiver Operating Characteristics CurveModel Performance Metrics

Association between Left Ventricular Geometry, Systolic Ejection Time, and Estimated Glomerular Filtration Rate in Ambulatory Patients with Preserved Left Ventricular Ejection Fraction

Plain Language SummaryCardiac function is important to quantify for risk stratification. Although left ventricular ejection fraction is commonly used, and identifies patients with poor systolic function, other easily acquired measures of cardiac function are needed. In this retrospective cohort study of 375 patients with increased left ventricular relative wall thickness, an easily derived measure from standard transthoracic echocardiography was independently associated with a surrogate of subclinical systolic dysfunction, left ventricular ejection time, and chronic kidney disease. Left ventricular geometry identifies clinically relevant subclinical systolic dysfunction and patients with worse kidney function.

Assessment of left ventricular myocardial systolic dysfunction in premature ovarian insufficiency patients using echocardiographic layer-specific myocardial strain imaging

BackgroundDue to the lack of oestrogen, premature ovarian insufficiency (POI) is an independent risk factor for ischaemic heart disease and overall cardiovascular disease. This study aimed to apply layer-specific myocardial strain for early quantitative evaluation of subclinical left ventricular myocardial systolic function changes in patients with POI.MethodsForty-eight newly diagnosed, untreated patients with POI (POI group) and fifty healthy female subjects matched for age, height and weight (control group) were enrolled. Standard transthoracic echocardiography was used to measure conventional parameters and layer-specific strain parameters.The layer-specific strain parameters included subendomyocardial global longitudinal strain (GLSendo), mid-layer myocardial global longitudinal strain (GLSmid), subepimyocardial global longitudinal strain (GLSepi), subendomyocardial global circumferential strain (GCSendo), mid-layer myocardial global circumferential strain (GCSmid), and subepimyocardial global circumferential strain (GCSepi). ResultsThere were no significant differences in age, body mass index (BMI), blood pressure, or left ventricular ejection fraction (LVEF) between the two groups. The end-diastolic interventricular septal thickness (IVST) was greater in the POI group (8.29 ± 1.32 vs. 7.66 ± 0.82, P = 0.008), and the POI group had lower E, E/A, and lateral e′ (all P < 0.05). As for systolic functions,the POI group had lower GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi (all P < 0.05).The intraobserver and interobserver coefficients of GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi were greater than 0.900. ConclusionsPOI patients with normal LVEF may suffer from subclinical left ventricular myocardial systolic dysfunction. Echocardiography of layer-specific myocardial strain could more sensitively detect subclinical impairment of left ventricular systolic function in POI patients.Graphical abstract

Comparison of the Application Value of Transthoracic Echocardiography in Diagnosing Patent Foramen Ovale Under Different States of Stimulation: A Retrospective Study.

This study aims to evaluate the application value of contrast-enhanced transthoracic echocardiography (cTEE) in the diagnosis of patent foramen ovale (PFO) under different states of stimulation, with the goal of enhancing the accuracy and efficiency of PFO diagnosis. This research consecutively enrolled patients suspected of having PFO from October 2022 to February 2024, presenting primary clinical symptoms such as unexplained syncope, headache, dizziness, and stroke. Patients underwent standard transthoracic echocardiography (TTE) and cTEE under three different states of stimulation (resting state, coughing, and Valsalva maneuver). Based on the presence of microbubbles in the left heart and their initial appearance time, patients were classified into PFO and control groups, with further diagnostic confirmation via transesophageal echocardiography (TEE) or foramen ovale closure procedures. The study results revealed significant differences between the PFO and control groups regarding age (p = 0.034) and headache symptoms (p = 0.001). In the PFO group, TTE showed a higher positivity rate both at rest and during coughing, highlighting the association between PFO and specific clinical symptoms. The number of microbubbles observed during TTE increased significantly under various stimulation states, particularly during the Valsalva maneuver (p < 0.05). This increase became more pronounced as the duration of the maneuver was extended, underscoring the differential response of PFO patients under varied physiological testing conditions, especially during prolonged Valsalva maneuvers. The study confirms the significant value of cTEE in diagnosing PFO under different stimulation states, particularly emphasizing the application of the Valsalva maneuver to significantly improve the sensitivity and specificity of PFO detection. Thus, incorporating cTEE examinations under various stimulation states holds significant clinical importance for enhancing the accuracy and efficiency of PFO diagnosis.

Use of artificial intelligence‐guided echocardiography to detect cardiac dysfunction and heart valve disease in rural and remote areas: Rationale and design of the AGILE‐echo trial

Transthoracic echocardiography (TTE) is essential in the diagnosis of cardiovascular diseases (CVD), including but not limited to heart failure (HF) and heart valve disease (HVD). However, its dependence on expert acquisition means that its accessibility in rural areas may be limited, leading to delayed management decisions and potential missed diagnoses. Artificial intelligence-guided (AI)-TTE offers a solution by permitting non-expert image acquisition. The impact of AI-TTE on the timing of diagnosis and early initiation of cardioprotection is undefined. AGILE-Echo (use of Artificial intelligence-Guided echocardiography to assIst cardiovascuLar patient managEment) is a randomized-controlled trial conducted in 5 rural and remote areas around Australia. Adults with CV risk factors and exercise intolerance, or concerns regarding HVD are randomized into AI-TTE or usual care (UC). AI-TTE participants may have a cardiovascular problem excluded, identified (leading to AI-guided interventions) or unresolved (leading to conventional TTE). UC participants undergo usual management, including referral for standard TTE. The primary endpoint is a composite of HVD or HF diagnosis at 12-months. Subgroup analysis, stratified based on age range and sex, will be conducted. All statistical analyses will be conducted using R. Of the first 157 participants, 78 have been randomized into AI-TTE (median age 68 [IQR 17]) and 79 to UC (median age 65 [IQR 17], P = .034). HVD was the primary concern in 37 participants (23.6%) while 84.7% (n = 133) experienced exercise intolerance. The overall 10-year HF incidence risk was 13.4% and 20.0% (P = .089) for UC and AI-TTE arm respectively. Atrial remodeling, left ventricular remodeling and valvular regurgitation were the most common findings. Thirty-three patients (42.3%) showed no abnormalities. This randomized-controlled trial of AI-TTE will provide proof-of-concept for the role of AI-TTE in identifying pre-symptomatic HF or HVD when access to TTE is limited. Additionally, this could promote the usage of AI-TTE in rural or remote areas, ultimately improving health and quality of life of community dwelling adults with risks, signs or symptoms of cardiac dysfunction.

The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography.

Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/'preserved' left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258-271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient's bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59-G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.

Artificial Intelligence Assessment of Biological Age From Transthoracic Echocardiography: Discrepancies with Chronologic Age Predict Significant Excess Mortality

Age and sex can be estimated using artificial intelligence on the basis of various sources. The aims of this study were to test whether convolutional neural networks could be trained to estimate age and predict sex using standard transthoracic echocardiography and to evaluate the prognostic implications. The algorithm was trained on 76,342 patients, validated in 22,825 patients, and tested in 20,960 patients. It was then externally validated using data from a different hospital (n=556). Finally, a prospective cohort of handheld point-of-care ultrasound devices (n=319; ClinicalTrials.gov identifier NCT05455541) was used to confirm the findings. A multivariate Cox regression model was used to investigate the association between age estimation and chronologic age with overall survival. The mean absolute error in age estimation was 4.9years, with a Pearson correlation coefficient of 0.922. The probabilistic value of sex had an overall accuracy of 96.1% and an area under the curve of 0.993. External validation and prospective study cohorts yielded consistent results. Finally, survival analysis demonstrated that age prediction ≥5years vs chronologic age was associated with an independent 34% increased risk for death during follow-up (P<.001). Applying artificial intelligence to standard transthoracic echocardiography allows the prediction of sex and the estimation of age. Machine-based estimation is an independent predictor of overall survival and, with further evaluation, can be used for risk stratification and estimation of biological age.

Assessment of subclinical left ventricular systolic and diastolic dysfunction in patients with type 2 diabetes mellitus under follow-up at Tikur Anbessa specialized hospital, Ethiopia: a case-control study

BackgroundIndividuals with diabetes mellitus are at increased risk of cardiovascular diseases, which in turn are the most common cause of morbidity and mortality in the diabetic population. A peculiar feature of cardiovascular diseases in this population is that they can have significant cardiac disease while remaining asymptomatic. There is a paucity of data regarding subclinical cardiac imaging features among diabetic adults in Africa, particularly in Ethiopia. This study was conducted to compare the magnitude and spectrum of left ventricular systolic and diastolic dysfunction among asymptomatic type 2 diabetic adults versus a normotensive, non-diabetic control group and to evaluate the determinants of left ventricular diastolic and systolic dysfunction.MethodsThis was a case-control study conducted at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. A standard transthoracic echocardiography was done for all study participants with type 2 diabetes mellitus and their normotensive and non-diabetic controls. Structured questionnaires were used to collect demographic and clinical characteristics and laboratory test results. Statistical analysis was done using the SPSS 25.0 software. The data was summarized using descriptive statistics. Bivariate and multivariate analysis was performed to determine the association between variables and echocardiographic parameters. The strength of statistical association was measured by adjusted odds ratios and 95% confidence intervals, with significant differences taken at p < 0.05.ResultsWe analyzed age- and sex-matched 100 participants in the study (diabetic) group and 200 individuals in the control group. Left ventricular systolic and diastolic dysfunction were significantly more prevalent among diabetic adults than their sex and age matched controls. Among diabetic individuals, ages of 60 years and above, dyslipidemia, use of Metformin and Glibenclamide, high serum triglyceride level, presence of neuropathy and use of statins correlated significantly with the presence of left ventricular diastolic dysfunction. Chronic kidney disease and neuropathy were determinants of left ventricular systolic dysfunction.ConclusionLeft ventricular systolic and diastolic dysfunction were significantly more prevalent among diabetic patients than their sex- and age-matched controls in our study. We recommend early screening for subclinical left ventricular dysfunction, especially in the elderly and in those with chronic kidney disease, dyslipidemia, and microvascular complications such as neuropathy.

Evaluation of Left Ventricular Function in Patients With Severe Aortic Stenosis Utilizing Automated Cardiac Motion Quantitation Techniques

ObjectiveThe objective of this study is to explore the patterns of alteration in left ventricular systolic function among patients with severe aortic stenosis (SAS) through the application of automatic myocardial motion quantification (aCMQ) techniques. Furthermore, we seek to ascertain dependable quantitative markers for the assessment of impaired left ventricular function in patients with SAS and an ejection fraction (EF) ≥ 60%. MethodsSeventy patients who underwent echocardiography and received a diagnosis of severe aortic stenosis (SAS) in the hospital from November 2021 to August 2022 were selected for the SAS group and categorized into three subgroups based on ejection fraction (EF)—SAS group with EF ≥ 60%, SAS group with EF ranging from 50% to 59%, and SAS group with EF < 50%. Concurrently, 30 healthy individuals were recruited at the hospital during the same timeframe to serve as the control group. Participants from both groups underwent standard transthoracic echocardiography to assess conventional echocardiographic parameters. Dynamic images were examined using automatic myocardial motion quantification (aCMQ) software to derive longitudinal peak strain (LPS) parameters, which were then subjected to statistical analysis. ResultsIn comparison to the control group participants, the measurements of ascending aorta diameter (AoD), left atrium diameter (LAD), interventricular septal end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), peak systolic velocity (Vmax), and mean pressure gradient (MPG) were significantly higher in the SAS groups (p < 0.05). When compared to participants in the SAS group with an EF ≥ 60%, the values of IVSd, LVPWd, Vmax, and MPG in the SAS group with EF ranging from 50% to 59% were significantly elevated (p < 0.05). Similarly, left ventricular end-diastolic diameter (LVEDD), the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e'), and the ratio of early to late diastolic mitral inflow velocities (E/A) in the SAS group with EF < 50% were significantly elevated (p < 0.05). The absolute values of longitudinal peak strain (LPS) in the SAS groups were significantly lower in comparison to those in the control group (p < 0.05). Furthermore, all measurements of left ventricular global longitudinal systolic peak strain (GLPS) showed a positive correlation with MPG, a moderate negative correlation with aortic valve area index (AVAI), and a moderate positive correlation with E/A. ConclusionsPatients with SAS and an EF < 50% exhibited the most profound impairment in left ventricular myocardial function. Utilizing the aCMQ technique enables the precise and quantitative evaluation of the severity of impaired left ventricular systolic function in patients within the SAS group with an EF ≥ 60%.

The Association Between Ascending Aortic and Left Ventricular Dimensions in Patients After Aortic Valve Replacement.

Aortic valve replacement (AVR) is often recommended for patients with severe aortic stenosis or chronic aortic regurgitation. These conditions result in remodeling of the left ventricle, including increased interstitial fibrosis that may persist even after AVR. These structural changes impact left ventricular (LV) mechanics, causing compromised LV diameter to occur earlier than reduced LV ejection fraction (LVEF). The aim of this study was to examine the effect of left ventricular end-diastolic diameter (LVEDD) and its role in aortic expansion one year after AVR. Sixty-three patients who underwent AVR were evaluated. All patients underwent standard transthoracic echocardiography, which included measurements of the ascending aorta, aortic root, LVEF, and LVEDD before the surgery and one year postoperatively. Correlations between these variables were calculated. All patients underwent AVR with either a mechanical or biological prosthetic aortic valve. Following AVR, there was a significant decrease in the dimensions of the ascending aorta and aortic root (both P=0.001). However, no significant changes were observed in LVEDD and LVEF. Correlations were found between the preoperative ascending aortic size and the preoperative and one-year postoperative LVEDD (r=0.419, P=0.001 and r=0.320, P=0.314, respectively). Additionally, there was a correlation between the postoperative ascending aortic size and the preoperative and one-year postoperative LVEDD (r=0.320, P=0.003 and r=0.136, P=0.335, respectively). The study findings demonstrate a significant correlation between the size of the aortic root and ascending aorta, before and after AVR. Additionally, a notable correlation was observed between postoperative LVEDD and the size of the aortic root.

Morphometric variants of remodeling and diastolic function of the left ventricle in late postmenopausal patients with vitamin D deficiency

Aim. To reveal the features of the structural-geometric remodeling of the left chambers of the heart, the diastolic function of the left ventricle and to assess the presence of calcification of the valvular structures of the heart in late postmenopausal women with different levels of vitamin D. Material and methods. The cross-sectional study included 123 postmenopausal women. A standard transthoracic echocardiography was performed with an assessment of morphometric variants of remodeling of the left chambers of the heart and its diastolic function according to the transmitral flow. The significance of differences was assessed using the Mann–Whitney test, χ2 Pearson. Differences and correlations were considered significant at p &lt; 0.05. Results. The median concentration of 25(OH)D in the sample was 20.51 ng/ml (15.8÷26.73). Adequate serum concentration of 25(OH)D was observed in 23 (19%) patients (group 1), in 100 (81%) cases vitamin D deficiency was detected (group 2). In group 1 — 7 (31%) patients had normal geometry (NG) of the left ventricle (LV), LV concentric remodeling (CR) was diagnosed in 1 (4%) case, LV concentric hypertrophy (CH) was diagnosed in 3 (13%) cases, and LV eccentric hypertrophy (EH) was detected in 12 (52%) cases. In Group 2, LV NG was diagnosed in 27 (27%) cases, LV CR was detected in 8 (8%) cases, LV CH was detected in 31 (31%) cases, and LV EH was verified in 34 (34%) cases, the differences are insignificant (p = 0.24). Patients of group 2 showed a statistically significant increase in the volume of the right atrium (RA) and thickness of the posterior wall of the left ventricle (TZSLV). In group 1, in 11 (50%) cases, rigid-type diastolic dysfunction (DD) was detected, and in 11 (50%) cases, a pseudo-normal type of DD was detected. In group 2, pseudonormal myocardial DD was detected in 26 (26%) patients, 74 (74%) patients had rigid-type DD, differences between groups were significant (p &lt; 0.001). Calcifications were found in the annulus fibrosus in 16 (70%) cases in group 1 and in 88 (88%) patients in group 2, the differences were significant (p = 0.04). Conclusion. In the study, data were obtained indicating a significant contribution of vitamin D deficiency to changes in the geometry of the left chambers of the heart, diastolic function of the left ventricle, and calcification of valvular structures.

Abstract WMP39: Incorporation of Automated Robotic Transcranial Doppler to Screen for Patent Foramen Ovale and Quantify Right to Left Shunt Severity in the Evaluation of Ischemic Stroke Patients for Stroke Etiology at a Comprehensive Stroke Center

Background: Patent foramen ovale (PFO) as a source of right-left shunting (RLS) is a recognized risk factor for recurrent stroke in young patients. Current standard care for RLS diagnosis includes transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and manual transcranial Doppler (TCD) which have disadvantages. The purpose of this retrospective review is to evaluate incorporation of an automated robotic TCD (rTCD) into the standard evaluation for RLS as cause of stroke, as prior studies have indicated higher sensitivity and quantification of RLS size to direct cardiology referral for potential PFO closure. Methods: Between Dec 2021-Oct 2022, 200 stroke patients age &lt;65 were included in this retrospective review. Average age was 55.7 ± 11.1 yrs. All patients had standard TTE and an rTCD (NovaSignal) with saline bubble injection at rest and Valsalva strain for assessment of RLS performed by echo and ultrasound technicians. Neurologists read results, including RLS shunt severity using the Spencer Shunt Grading scale (0-5), where Grade 3-5 is considered large. Results: The rate of positive RLS shunt using rTCD was 55.5% (n=111), of which 23.5% (n=47) were Spencer grade 3+ or higher. No bone window rate was 8.5% (n=17), which is lower than reported manual TCD rates. There were no rTCD RLS shunt negative patients who had a positive TTE or TEE. Of patients who had positive rTCD (n=14) and TTE with bubble, only 5 TTE’s were positive (35.7% sensitivity). Of rTCD positive patients (n=23) who also had TEE with bubble, only 11 were positive (48% sensitivity). And of 15 rTCD Grade 3+ RLS, only 11 TEE with bubble were positive (73% sensitivity). Conclusion: We successfully replaced rTCD for TTE with bubble to screen for RLS on patients who were admitted with a stroke or TIA, with the following advantages. Non-TCD technicians could be trained to perform the tests with accuracy. rTCD was more sensitive in detecting RLS than TTE with bubble. Quantification of RLS severity identified stroke patients with potentially higher risk of recurrence, prioritized to more aggressive medical management and cardiology referral for TEE and potential PFO closure.

Feasibility and prognostic significance of ventricular-arterial coupling after myocardial infarction: the RIGID-MI cohort.

The clinical significance and feasibility of the recently described non-invasive parameters exploring ventricular-arterial coupling (VAC) remain uncertain. This study aimed to assess VAC parameters for prognostic stratification in stable patients with left ventricular ejection fraction (LVEF) ≥40% following myocardial infarction (MI). Between 2018 and 2021, patients with LVEF ≥40% were evaluated 1 month following MI using transthoracic echocardiography (TTE) and arterial tonometry at rest and after a handgrip test. VAC was studied via the ratio between arterial elastance (Ea) and end-systolic LV elastance (Ees) and between pulse wave velocity (PWV) and global longitudinal strain (GLS). Patients were followed for major adverse cardiovascular events (MACE): all-cause death, acute heart failure, stroke, AMI, and urgent cardiovascular hospitalization. Among the 374 patients included, Ea/Ees and PWV/GLS were obtained at rest for 354 (95%) and 253 patients (68%), respectively. Isometric exercise was workable in 335 patients (85%). During a median follow-up of 32 months (interquartile range: 16-42), 41 (11%) MACE occurred. Patients presenting MACE were significantly older and had a higher prevalence of peripheral arterial disease, lower GLS, higher Ea, PWV, and PWV/GLS ratio. The Ea/Ees ratio and standard TTE parameters during isometric exercise were not associated with MACE. After adjustment, the PWV/GLS ratio was the only VAC parameter independently associated with outcome. Receiver operating characteristic curve analysis identified a PWV/GLS ratio >0.70 (Youden's index = 0.37) as the best threshold to identify patients developing MACE: hazard ratio (95% confidence interval) = 2.2 (1.14-4.27), P = 0.02. The PWV/GLS ratio, assessed 1 month after MI, identifies a group of patients at higher risk of MACE providing additional value on top of conventional non-invasive parameters.

Efficacy and safety of use of ultrasound enhancing agent in patients hospitalized with COVID-19

PurposeThe efficacy and safety of ultrasound enhancing agent (UEA) was unknown in the COVID-19 hospitalized patients. We set out to establish the utility of UEA and its safety profile.MethodsA retrospective observational study of prospectively assessed hospitalized patients referred for transthoracic echocardiography (TTE) for suspected cardiac pathology due to COVID-19. The indications and subsequent ability to answer the indications for all TTE were reviewed, as well as impact on diagnosis and management. UEA safety was considered through 48 h mortality.ResultsFrom a total of 364 patients (mean age 64.8yrs, 64% males) hospitalized with COVID-19 with TTE requested, an indication could be identified in 363, and 61 required administration of UEA. Standard TTE was able to answer the original indication in 275 (75.8%) patients. This was increased to 322 (88.7%) patients, a relative increase of 17.1%, with the use of UEA (p < 0.001). There was subsequent change in diagnosis in 22 out of 61 (36%) patients receiving UEA and change in management in 13 out of 61 (21.3%). There was no significant increase in 48 h (p = 0.14) mortality with UEA use. The patient population of TTE with UEA versus TTE without UEA differed in having a higher incidence of left ventricular systolic dysfunction, right ventricular dilatation, and self-defined white ethnicity.ConclusionThe use of UEA in COVID-19 hospitalized patients, including those who were critically ill, provided incremental information when compared to TTE without UEA resulting in both changes in diagnosis and management plan and appears to be safe.

Prognostic Relevance of Global Myocardial Work Index in Patients with Moderate Aortic Valve Stenosis.

A reduced global myocardial work index (GWI) ≤ 1951 mmHg% is associated with increased mortality in patients with severe aortic valve stenosis (AS). However, parameters predicting the outcome in patients with moderate AS are limited. Therefore, the aim of this study was to evaluate the prognostic value of the GWI in patients with moderate AS. In this prospective study, 103 patients with moderate AS (mean age 72 ± 10 years; male: 69%) underwent standardized transthoracic echocardiography. The primary endpoint was survival without an aortic valve replacement (AVR). After a median follow-up of 30 ± 5 months, 37 patients (36%) were referred for an AVR. Survival without an AVR was 96% at 12 months and 80% at 30 months (>1951 mmHg%) versus 96% and 68% (≤1951 mmHg%). A GWI ≤ 1951 mmHg% did not predict the need for an AVR (hazard ratio 1.31 (95% CI, 0.63-2.72), p = 0.49). Furthermore, there was no significant correlation between the mean GWI (1644 ± 448 mmHg%) and mean aortic valve pressure gradient (24.2 mmHg ± 6.2, p = 0.615) or effective aortic orifice area (1.24 cm2 ± 0.11, p = 0.678). There was no difference between the AVR and non-AVR groups in the occurrence of clinical symptoms. In contrast to patients with severe AS, a GWI ≤ 1951 mmHg% did not predict the need for an AVR. Further research is needed to improve the risk stratification in patients with moderate AS.

Maternal pre-existing and gestational diabetes and the risk of bicuspid aortic valve in the offspring

Abstract Background Approximately 6% of all pregnancies in Denmark are affected by maternal pre-existing or gestational diabetes. Maternal diabetes is a well-known risk factor for congenital heart defects. Among the most common congenital heart defects is bicuspid aortic valve (BAV), which is present in 0.8% of newborns. Familial clustering of BAV is seen in 30-40%, but the heritability is not completely understood and since most cases are sporadic, a multifactorial aetiology has been proposed. The association between maternal diabetes and BAV in the offspring has been sparsely investigated previously. Purpose The purpose was to assess the prevalence of BAV in newborns born to mothers with pre-existing or gestational diabetes compared with children born to mothers without diabetes. Method Systematic, standardized transthoracic echocardiography was performed within 60 days of birth in over 25,000 newborns included in a population-based, multicentre, cohort study between 2016 and 2018. Maternal diabetes-status was collected from obstetrical records maintained by the obstetrical departments of the participating hospitals, supplemented by records from a nationwide registry covering patients contacts with private and public hospitals since 1976. Maternal diabetes was categorized as type 1, type 2, or gestational diabetes (GDM) using the ICD-10 codes DO240, DO241, and DO244, respectively. The exposed newborns were compared with newborns not exposed to maternal diabetes. Results In total, the cohort consisted of 25,553 new-borns of whom 24,707 (96.7%) were not exposed to diabetes, 648 (2.5%) were exposed to GDM, and 198 were exposed to pre-existing diabetes; 136 (0.5%) to type 1 and 62 (0.2%) to type 2 diabetes. Median gestational age was 281 days (interquartile range (IQR) 273;287), median age at examination was 11 days (IQR 7;15), and 48% were female. None of the newborns exposed to pre-existing diabetes had a BAV. Nine (1.4%) new-borns exposed to GDM, and 179 (0.7%) newborns not exposed to diabetes were found to have a BAV, corresponding to a relative risk of 1.92 (95%CI 0.99-3.73), p= 0.056. Conclusion Exposure to maternal diabetes is associated with an increased risk of congenital heart disease. In our large cohort of unselected newborns, the association between diabetes and BAV did not reach statistical significance, but the numerically observed twice higher risk of BAV in children born to women with gestational diabetes is nevertheless intriguing and deserves future attention.

The prognostic role of left atrial strain in young patients after ST elevation myocardial infarction: a 3D echocardiographic study

Abstract Background LA volume previously demonstrated its role as significant predictor of adverse events after AMI. The prognostic value of LA strain is less studied. Left atrial strain has been used as a more accurate alternative to assessing LA performance. 3D echocardiography compared with 2D measurements better reflect the entire atrial myocardium, leading to a more accurate estimation of LA function. Purpose In this study we aimed to assess the prognostic value of LA strain parameters determined by 3D echocardiography in young patients after STEMI. Patients and methods: We enrolled 112 patients in this study - 84 young patients with a first STEMI treated by primary PCI and 28 healthy age and sex matched controls. All patients underwent standard transthoracic echocardiography. In addition to conventional echocardiographic parameters, 3D acquisitions of the left atrium were performed. 3D LA longitudinal strain parameters were determined using the automated function 4D Auto LAQ. Patients were followed up for one year after STEMI, the primary endpoint being the occurrence of MACE. Results Compared to the control group, patients with STEMI had lower values of all LA strain parameters. There were also significant differences between MACE and non-MACE groups. Patients with MACE at follow up had lower reservoir strain (15.16 ± 2.58 vs. 22.71 ± 5.25), lower conduction strain (-8.62 ± 1.77 vs. -10.97 ± 1.44) and lower pumps strain (-9.36 ± 1.51 vs. -12.73 ± 2.53), compared to those from the non-MACE group. All LA strain parameters proved to have very good predictive abilities for MACE in ROC analysis (AUC = 0.894, 95 %CI, P &amp;lt; 0.0001 for LASr 3D, AUC = 0.854, 95 %CI, P &amp;lt; 0.0001 for LASct 3D, and AUC = 0.883, 95%CI, P &amp;lt; 0.0001 for LAScd 3D). For each variable we determined a cut off value as follows: 17.5 (Sb 91.7%, Sp 86.7%) for LASr 3D, -10.5 (Sb 75% Sp 86.7%) for LASct 3D, and -9.05 (Sb 75% Sp 91.7%) for LAScd 3D. LASr 3D under 17, and LASct 3D over -10.5 determined an approximately 2-fold increase in adverse events after STEMI. Univariate COX regression analysis showed that all parameters had a significant effect on MACE, while multivariate analysis identified only reservoir and pump functions as independent predictors for adverse events. LASr 3D values showed a proportional decrease with worsening diastolic dysfunction, demonstrating significant differences between diastolic dysfunction grades. We determined LASr 3D cut-off values for discriminating between different degrees of diastolic dysfunction. Conclusion 3D LA reservoir and pump strain proved to be independent predictors for MACE at one year follow up after STEMI in young patients. Beyond its prognostic role, LASr 3D may be helpful as a complementary method to evaluate diastolic dysfunction in young STEMI patients. Further larger scale studies are needed to validate these findings.

Systolic function of the left and right ventricles and myocardial strain in young adults with metabolic syndrome

The purpose of this article is to evaluate the systolic function of the left and right ventricles and measure myocardial Strain in young people (from 18 to 44 years old) with a newly established clinical and laboratory diagnosis of metabolic syndrome (MS) according to the criteria of the International Diabetes Federation (IDF), to identify possible early markers of myocardial dysfunction. All patients underwent standard transthoracic echocardiography (EchoCG) with assessment of systolic function of the left and right ventricles (LV and RV). The work detects early markers of ventricular myocardial dysfunction using speckle tracking 2D and 4D EchoCG, and also investigates the relationship between the main components of MS and echocardiographic parameters. With the help of a comparative analysis, statistical data were revealed on the low global longitudinal strain of the left and right ventricle in 2D and 4D in the main group compared with the control group. In individuals with MS, the mean values of global circular strain (GCS), radial (GRS) strain and global area strain (GAS) of the left ventricle were also significantly lower than the control group. Indicators obesity diseases (body weight and waist circumference) had a negative correlation with the ejection fraction (EF) and parameters of ventricular strain.

Abstract 15237: Feasibility and Diagnostic Accuracy of Handheld Echocardiography in Patients Hospitalized With Acute Coronary Syndrome

Introduction: Transthoracic echocardiography (TTE) is recommended in every acute coronary syndrome (ACS) patient, but is time-consuming and not always deliverable. Development of handheld echocardiography (HHE) devices provide a fast, low-cost method to facilitate rapid bedside clinical assessment of those patients. Hypothesis: We hypothesized that evaluation of hospitalized ACS patients using HHE is feasible and provide similar information to standard TTE in detecting important cardiac pathology. Methods: Patients admitted with ACS were prospectively enrolled, and underwent both bedside HHE (Philips Lumify) and clinical TTE evaluation. Independent analysis of HHE and TTE images was performed by a blinded expert team to determine key predetermined imaging findings that might alter management of ACS patients (Table 1). The TTE analysis was repeated for these variables after 1 month. Agreement of HHE vs TTE was assessed with kappa statistics and compared to agreement of TTE vs TTE as reference standard. Results: The analysis included 108 patients (mean age 65y, 78% male). Duration of HHE was a third faster than targeted clinical TTE (8.2±1.8min vs 12.1±5.0min; p&lt;0.001). Agreement in detecting the following variables was good (&gt;0.60) and similar for HHE vs TTE compared to TTE vs TTE: left ventricle (LV) dilatation, LV hypertrophy, LV ejection fraction &lt;40%, anterior and inferior wall motion abnormalities, right ventricle (RV) dilatation, pericardial effusion, aortic stenosis, ventricle septum defect, and takotsubo cardiomyopathy. Agreement between HHE vs TTE was less good than TTE vs TTE for detection of lateral wall motion abnormalities, RV dysfunction, and LV thrombus. Conclusions: In ACS patients, bedside HHE is faster and provides similar diagnostic information to TTE for the majority of key echo findings. However, important exceptions exist, in particular HHE is less good at detecting lateral wall motion abnormalities, RV dysfunction and LV thrombus.