Two-chamber Views Research Articles

True-MAD and pseudo-MAD in consecutive patients undergoing cardiovascular magnetic resonance

Abstract Background Mitral annulus disjunction (MAD) is a controversial imaging entity with uncertain clinical significance, which has been either considered a pathological entity potentially related to mitral valve prolapse (MVP) and sudden cardiac death or, on the contrary, a benign finding in normal hearts. Cardiovascular magnetic resonance (CMR) is poised to be the ideal imaging modality to assess MAD. Recently, a distinction between pseudo-MAD, present only in systole and secondary to juxtaposition of the billowing posterior leaflet on the adjacent left atrial wall, and true-MAD, where the insertion of the posterior leaflet is clearly displaced on the atrial wall either in diastole or in systole, has been suggested. Purpose We aimed to investigate the prevalence of pseudo-MAD and true-MAD in consecutive patients undergoing clinically-referred CMR. Methods This was a single-center retrospective study including consecutive patients referred to CMR from September 2023 to November 2023. Patients with feasible MAD assessment were included. MAD was defined as a ≥1 mm displacement between the left atrial wall-mitral valve leaflet junction hinge and the top of the left ventricular wall, measured from cine-CMR images in the three long-axis views. Pseudo-MAD and true-MAD were defined according to the presence of MAD only in systole or both in systole and diastole, respectively. MVP was defined as a systolic displacement ≥2 mm of one or both mitral valve leaflets above the annulus in 3-chamber view. Results Two-hundred-ninety patients (mean age 57±18 years; 181 men, 62%) were included. MVP and MAD were respectively found in 24 (8%) and 145 (50%) patients, of which 98 (34%) with true-MAD and 47 (16%) with pseudo-MAD. In all measurements, systolic MAD (2.6±1.3 mm) resulted equal to or greater than diastolic MAD (2.2±1.1 mm). The most frequent MAD location was the inferior wall in the two-chamber view (42%), whereas the rarest one was the inferolateral wall in the three-chamber view (17%). In patients with MVP, the prevalence of MAD was higher when considering all long-axis views (22 patients, 92%), of which 50% presented with true-MAD and 50% with pseudo-MAD. The extent of pseudo-MAD and true-MAD were both greater in patients with MVP (4.2±1.5 mm and 3.0±1.6 mm, respectively) than in those without MVP (2.3±1.0 and 2.1±0.9 mm; p<0.001 and p=0.007, respectively) in all locations. At the level of the inferolateral wall, the prevalence of MAD was 71% vs. 12% (p<0.001) in patients with vs. without MVP. Conclusions The presence of true-MAD was a common imaging finding in consecutive patients undergoing CMR, thus not resulting in a distinctive abnormal feature related to MVP or sudden cardiac death. Patients with MVP showed higher prevalence and extent of true-MAD and pseudo-MAD in all locations, in line with greater degeneration of the mitral annulus. Larger studies are needed to identify potential malignant characteristics of MAD.True-MAD (A,B) and pseudo-MAD (C,D).

Prognostic value of echocardiographic parameters in predicting major adverse cardiac events one year following st-segment elevation myocardial infarction

Abstract Approximately 50% of patients who survive an ST-segment elevation myocardial infarction (STEMI) experience irreversible damage to the heart muscle, which increases long-term risk of developing heart failure. Moreover, cardiovascular mortality constitutes half of all deaths. This research aimed to determine the best combination of patient data collected during a one-year follow-up period to enhance the accuracy of outcome predictions for patients with STEMI. Methods In this study, 246 patients who experienced STEMI and older than 18 were prospectively monitored. All participants received primary percutaneous coronary intervention treatment. The study's primary outcomes, observed over the year following hospital discharge, included cardiovascular death, recurrent myocardial infarction, newly diagnosed heart failure, and arrhythmias or conduction issues. Of the patients, 18% of patients reached the primary outcomes. Two-dimensional transthoracic echocardiography was conducted 3-5 days after the initial event to assess left ventricular global longitudinal strain (GLS) using 2D speckle-tracking echocardiography on the apical four-chamber, two-chamber, and long-axis views. Left ventricular mechanical dispersion was calculated as the standard deviation of the time from the Q/R wave onset to peak GLS across 17 segments of the left ventricle. Results The findings revealed that the overall GLS was -10.70 (-12.61 to -8.40), but in patients who met the study's primary outcomes, GLS was significantly lower at -7.83 (-8.70 to -6.90), compared to -12.02 (-13.11 to -10.17) in those who did not, with a significant difference (p=0.00001). Mechanical dispersion was 40.24±26.56 in the entire cohort but significantly higher at 65.62±22.57 in the outcome group compared to 25.79±14.81 in the non-outcome group (p=0.00001). The ejection fraction averaged 48.97±7.69% across all patients, 47.22±7.16% in those with outcomes, and 49.92±7.84% in those without, with a statistically significant difference (p=0.039). Cox regression analysis identified key predictors of major adverse cardiac events (MACE) within one year after STEMI, including global longitudinal strain (p=0.0006), left atrium volume index (p=0.0448), left ventricular end-diastolic diameter (p=0.045), and mechanical dispersion (p<0.0001). A multivariate logistic regression analysis demonstrated that a combination of GLS, left ventricular end-systolic volume (LVESV), mechanical dispersion, and ejection fraction could predict 1-year MACE with high accuracy (χ2 = 85.18; p<0.0001, AUC=0.961 [0.903-0.989]). In conclusion, this study identifies crucial metrics, such as global longitudinal strain, left ventricular end-systolic volume, mechanical dispersion, and ejection fraction, as predictive factors for MACE one year following STEMI. This predictive model is straightforward, reproducible, and can be easily implemented in cardiology practice.

The importance of heart rate on left ventricular global longitudinal strain in echocardiography: novel insights facilitated by automated deep learning methods

Abstract Background Heart rate (HR) is assumed to influence echocardiographic measurements. Consequently, HR needs to be considered for accurate assessment of cardiac function. Despite left ventricular global longitudinal strain (LV GLS) being recognised as a valuable measure of cardiac function, its normal reference ranges remain confined to patients within a limited range of resting HR. So far, time-consuming manual analyses and high measurement variability have precluded comprehensive assessment of the interplay between HR and LV GLS. Using fully automated GLS measurements provided by novel deep learning (DL) methods, it is now possible to evaluate changes in LV GLS across a wide range of HR. Purpose To improve echocardiographic assessments across a wide range of HR intervals, we aimed to study the influence of controlled HR variations on LV GLS using programmable pacemakers and fully automated DL measurements. Methods Participants with sinus node dysfunction and implanted programmable pacemakers were enrolled. Echocardiographic acquisitions were obtained at baseline HR and during stepwise increments by 10 beats/min, targeting a range from 50 to 140 beats/min. Recordings of cine-loops including 10 cardiac cycles were obtained for the four-chamber, two-chamber, and apical long axis view. LV GLS was measured for all cycles using a fully automated DL method developed by our group, and presented as mean of the three standard apical views for all patients at each HR level. A linear mixed model was used for construction of an overall trendline based on the estimated fixed effects across all 50 patients, stating patient number as the random effect. The correlation between HR and LV GLS was evaluated by a likelihood ratio test. Results Fifty patients were included, 52% females, mean age 68 years (27 to 88 years). All patients had preserved atrioventricular conduction. Resting HR ranged from 50 to 87 beats/min (mean 64 beats/min). At baseline echocardiographic acquisition, most participants were within normal ranges for LV volumes, systolic and diastolic function. A total of about 13,000 cardiac cycles were automatically analysed by the DL method. The overall trend demonstrated a linear relation between increasing HR and decreasing absolute LV GLS (Figure 1). Across HR increments from 50 to 140 beats/min, there was a 32% (22%–42%) reduction in absolute LV GLS, declining from -17.1% to -11.7%. The strong correlation between changes in HR and LV GLS was further supported by a highly significant likelihood ratio test (p-value <0.001). Conclusions There was a reduction of absolute LV GLS with increasing HR. These findings emphasize the importance of integrating HR considerations into clinical echocardiography practice. Moreover, the results highlight that DL methods can unlock substantially richer insights from individual patient data, offering a new pathway towards more personalized and precise cardiac diagnostics.Figure 1

Automatic tablet-based monoplane quantification of stroke volume and left ventricular ejection fraction: A comparative assessment against computer-based biplane and monoplane tools.

Point-of-care cardiovascular left ventricle ejection fraction (LVEF) quantification is established, but automatic tablet-based stroke volume (SV) quantification with handheld ultrasound (HAND) devices is unexplored. We evaluated a tablet-based monoplane LVEF and LV volume quantification tool (AutoEF) against a computer-based tool (Tomtec) for LVEF and SV quantification. Patients underwent HAND scans, and LVEF and SV were quantified using AutoEF and computer-based software that utilized either apical four-chamber views (Auto Strain-monoplane [AS-mono]) or both apical four-chamber and apical two-chamber views (Auto Strain-biplane [AS-bi]). Correlation and Bland-Altman analysis were used to compare AutoEF with AS-mono and AS-bi. Out of 43 participants, eight were excluded. AutoEF showed a correlation of.83 [.69:.91] with AS-mono for LVEF and.68 [.44:.82] for SV. The correlation with AS-bi was.79 [.62:.89] for LVEF and.66 [.42:.81] for SV. The bias between AutoEF and AS-mono was 4.88% [3.15:6.61] for LVEF and 17.46mL [12.99:21.92] for SV. The limits of agreement (LOA) were [-5.50:15.26]% for LVEF and [-8.02:42.94] mL for SV. The bias between AutoEF and AS-bi was 6.63% [5.31:7.94] for LVEF and 20.62mL [16.18:25.05] for SV, with LOA of [-1.20:14.47]% for LVEF and [-4.71:45.94] mL for SV. LVEF quantification with AutoEF software was accurate and reliable, but SV quantification showed limitations, indicating non-interchangeability with neither AS-mono nor AS-bi. Further refinement of AutoEF is needed for reliable SV quantification at the point of care.

Impact of left atrial strain on clinical outcomes in patients with permanent pacemaker implantation.

This study aimed to investigate the clinical impact of pre-procedural left atrial strain (LAS) in patients undergoing permanent pacemaker implantation (PPI). This single-centre retrospective study enrolled 434 patients who were admitted for transvenous PPI between 2010 and 2020. After excluding patients with persistent atrial fibrillation, PPI for complete atrioventricular block, severe valvular disease, history of open-heart surgery and those without LAS data, 172 patients were analysed. The LAS was measured using commercially available software to calculate the average strain value of the apical four- and two-chamber views before PPI. The primary composite endpoint was hospitalization due to heart failure or cardiovascular death. Cox proportional hazard models were used to evaluate risk factors for the primary composite endpoint. The mean patient age was 78±8years, and 42% of the patients were men. PPI was performed for sick sinus syndrome in 64% and second-degree atrioventricular block in 36% of the patients. The pre-procedure left atrial reservoir strain (LASr) was 28±11%. The median follow-up period was 4.7years, and the primary endpoint was observed in 23 (13%) patients. In multivariate Cox proportional risk analysis, LASr was independently associated with the primary composite endpoint (hazard ratio, 1.08 per 1% decrease; 95% confidence interval, 1.02-1.15; P=0.007). The receiver operating characteristic curve of the LASr for the primary composite endpoint showed a cutoff value of 21% (area under the curve 0.657, P=0.004). The prognostic impact of LASr was consistent with that of sick sinus syndrome and atrioventricular block. A decreased pre-procedure LASr was associated with long-term adverse outcomes after PPI use.

TTE apical two-chamber view suggested the disappearance of mitral valve vegetation after treatment.

TTE apical two-chamber view suggested the disappearance of mitral valve vegetation after treatment.

Subclinical impairment of left ventricular myocardium function in type 2 diabetes mellitus patients with or without hypertension

BACKGROUND Cardiovascular disease has been the leading cause of morbidity and mortality for type 2 diabetes mellitus (T2DM) patients over the last decade. AIM To determine whether layer-specific global longitudinal strain (GLS) combined with peak strain dispersion (PSD) can be used to assess left ventricle (LV) myocardium systolic dysfunction in T2DM patients or without hypertension (HP). METHODS We enrolled 97 T2DM patients, 70 T2DM + HP patients and 101 healthy subjects. Layer-specific GLS and PSD were calculated by EchoPAC software in apical three-, four- and two-chamber views. GLS of the epimyocardial, middle-layer and endomyocardial (GLSepi, GLSmid, and GLSendo) were measured and recorded. Receiver operating characteristic analysis was performed to detect LV myocardium systolic dysfunction in T2DM patients. RESULTS There were significant differences in GLSepi, GLSmid, GLSendo, and PSD between healthy subjects, T2DM patients and T2DM patients with HP (P < 0.001). Trend tests yielded the ranking of healthy subjects > T2DM patients > T2DM with HP patients in the absolute values of GLSepi, GLSmid and GLSendo (P < 0.001), while PSD was ranked healthy subjects < T2DM < T2DM with HP (P < 0.001). Layer-specific GLS and PSD had high diagnostic efficiency for detecting LV myocardium systolic dysfunction in T2DM patients, however, the area under the curve (AUC) for layer-specific GLS and PSD combined was significantly higher than the AUCs for the individual indices (P < 0.05). CONCLUSION Layer-specific GLS and PSD were associated with LV myocardium systolic dysfunction in T2DM patients, T2DM patients with HP. T2DM patients with HP have more severe LV myocardium systolic dysfunction than T2DM patients without HP and normal control patients. The combination of layer-specific GLS and PSD may provide additional prognostic information for T2DM patients with or without HP.

Effect of Ciprofol on Left Ventricular Myocardial Strain and Myocardial Work in Children Undergoing Cardiac Surgery: A Single-center Double-blind Randomized Noninferiority Study

ObjectiveTo compare the effect of ciprofol and propofol on left ventricular (LV) systolic function and myocardial work by noninvasive speckle-tracking echocardiography (STE) in children undergoing surgical repair of atrial septal defect (ASD) or ventricular septal defect (VSD). DesignSingle-center double-blind randomized non-inferiority study. SettingAt a tertiary care center affiliated to Shanghai Jiao Tong University, China. ParticipantsOne hundred and twelve children aged 1 month to 16 years old undergoing ASD or VSD surgery with cardiopulmonary bypass. InterventionsOne hundred and twelve children were allocated randomly into receiving ciprofol (n = 67) and propofol (n = 45) in a 1.5:1 ratio. Ciprofol or propofol were IV infused at loading doses of 0.4 mg/kg or 2.0 mg/kg respectively over 30 seconds depending on the physical condition of each patient. When the bispectral index was maintained between 45 - 55 after induction, transthoracic echocardiography including apical two-chamber, three-chamber and four-chamber views were collected at bedside. Measurements and Main ResultsOf total 112 patients enrolled, 104 completed the study. The global longitudinal strain (GLS) of ciprofol and propofol groups after anesthesia was -17.3% (95% CI, -18.0% to -16.6%) and -17.8% (-18.7 to -17.0%) in the full analysis set (FAS) and -17.5% (95% CI, -18.2% to -16.9%) and -17.8% (-18.7% to -17.0%) in the per-protocol set (PPS) respectively. The noninferiority margin was set as 2% and confirmed with a lower limit of two-sided 95% CI for the inter-group difference of 1.58% and 1.34% in the FAS and PPS. There were no significant differences between two groups in LV systolic and diastolic function and myocardial work indices. Postoperative vasoactive-inotropic score, NT-proBNP, duration of mechanical ventilation, length of stay in cardiac intensive care unit and hospital were also comparable between two groups (all p > 0.05). ConclusionsCiprofol did not show different effect from propofol on myocardial function and postoperative outcomes. Furtherly on sensitive cardiac systole marker GLS, ciprofol had noninferiority to propofol. Ciprofol might be alternative solution for cardiac anesthesia in CHD children with mild lesion.

Apical two-chamber heart view of TTE showing noncompaction of the left ventricular apical myocardium.

Apical two-chamber heart view of TTE showing noncompaction of the left ventricular apical myocardium.

Atrial cardiomyopathy by strain predicts atrial fibrillation in young Lamin A/C patients

Abstract Introduction Cardiac laminopathy is a malignant and highly arrhythmogenic form of dilated cardiomyopathy caused by variants in the lamin A/C (LMNA) gene. Atrial fibrillation (AF) is common during disease progression and often occurs at a young age, before evident structural cardiac changes and therefore, decision making on anticoagulation for AF is challenging. Whether atrial cardiomyopathy is present at this early stage of LMNA disease has not yet been explored. Purpose We aimed to evaluate for atrial cardiomyopathy in LMNA genotype positive subjects without prior atrial arrhythmias and assess whether atrial cardiomyopathy would be associated with the occurrence of AF during follow-up. Methods We prospectively recruited LMNA genotype-positive patients in a cohort study. Patients without prior documented atrial arrhythmias were evaluated for atrial cardiomyopathy by echocardiography. Atrial cardiomyopathy was evaluated by left atrial (LA) volume index (LAVI) and LA strain (peak reservoir strain and peak conduit strain). LA strain was assessed by 2D speckle-tracking echocardiography, averaged from apical four- and two-chamber views using a LA strain dedicated software with R-wave at end diastole as zero-reference point. Results We evaluated 129 LMNA genotype positive patients (51% women, age 40±15 years), of whom 57 patients (44%) had previous AF. Hence, we included 72 patients (32±14 years old, 49% female, left ventricular ejection fraction 53±11%) for assessment of atrial cardiomyopathy. The mean LA reservoir strain was 35±14%, conduit strain 25±13% and LAVI 38±23 ml/m2. During 7.7±5.0 years of follow-up, 28 (39%) patients developed AF after a median of 2.2 years. Patients with AF during follow-up had larger LAVI (47±30 vs. 32±10ml/m2, p=0.01) and worse LA reservoir strain (29±12% vs. 38±14%, p=0.02) at baseline than those who did not develop AF. LA reservoir strain and LAVI at baseline were both predictors of AF during short-term follow-up (HR 0.95 [CI 0.90-0.99], p=0.025 and HR 1.02 [CI 1.01-1.03], p=0.009, respectively), whereas LA conduit strain was not (HR 0.98 [CI 0.94-1.03], p=0.45). ROC analysis identified LA reservoir strain better than 32.5% as the best discriminating value for survival free of AF (log rank p=0.05) (Figure). Conclusion Atrial cardiomyopathy was common in LMNA genotype positive patients without previous atrial arrhythmias. LA volume and and LA reservoir strain predicted new onset AF during follow-up and may be used as markers for detecting short term risk of AF and potentially guide anticoagulation treatment in LMNA disease.LA reservoir strain and AF in LaminA/C

Sex-specific differences in bi-atrial strain in elite athletes: results from the ELITE cohort

Abstract Background Athletes frequently demonstrate increased atrial volumes as a result of physiological adaptation to sports. In the general population, atrial dilatation is associated with decreased atrial function, measured as atrial ejection fraction and strain. However, studies on bi-atrial function in athletes have been limited and have primarily focused on male endurance athletes. Purpose To determine sex-specific differences in left- and right atrial strain in elite athletes. Methods The study population consisted of elite athletes included in the ELITE-cohort older than 16 years of age and exercising ≥10 hours per week and competing at the highest national, international or Olympic level in the Netherlands. All included athletes underwent a standardised resting transthoracic echocardiogram. Left- and right atrial (LA/RA) reservoir-, conduit- and cntractile- strain were measured with grey-scale-based 2D Speckle tracking software in the four- and two-chamber views and bi-atrial volume and function parameters were collected. Results A total of 166 elite athletes were included (48.2% female, media age 25 years [22, 28]), with athletic disciplines road cycling 25.3%, hockey 16.9%, rowing 14.5%, soccer 12.7%, water polo 9.6%, sailing 6.0%, track cycling 3.6%, and other 11.6%. There were no sex differences in age and training hours (18 hours per week). Athletic disciplines were evenly distributed among female- and male athletes. Female athletes had a lower BSA than male athletes (1.8 cm2 [1.7, 1.9] vs 2.1 cm2 [1.9, 2.2], p <0.001). Female athletes had similar LAESVi (36.5 ml/cm2 [32.0, 42.0] vs 36.5 ml/cm2 [31.0, 47.8]) and LAESAi (11.2 cm2/m2 [9.5, 12.2] vs 10.6 cm2/m2 [9.0, 11.9]) compared with male athletes. Female athletes had a higher LAEF (63.2 ±6.2% vs 60.7 ±5.8%, p =0.007) and greater LA deformation than male elite athletes during the reservoir- (34.7 ±6.2% vs 31.4 ±4.9%, p <0.001) and conduit phase (-25.2 ±5.2% vs -22.6 ±3.7% p <0.001). LA deformation during the contractile phase (-9.0% [-12.0, -7.0] vs – 9.0% [-11,-7]) was similar (figure 1). Female athletes had a lower RAESVi (29.5 ml/m2 [25.2, 36.4] vs 35.3 ml/m2 [28.5, 41.9], p <0.01) but there were no differences in RAEF (42.6 ±10.3% vs 45.2 ±11.1%) and RAESAi (9.8cm2/m2 [8.8, 11.3] vs 10.1 cm2/m2 [8.8-11.3]). There were no differences in RA reservoir- (30.7 ±7.6% vs 29.4 ±8.0%), conduit (-21.4 ±6.6% vs -20 ±6.6%) and contractile strain (-9.0% [-11.0, -6.8] vs -9.0% [-11.8, -7.0]) (figure 2). Conclusion In both male and female elite athletes, the LA is of comparable area and volume. However, in female athletes LA deformation is greater during the reservoir and conduit phases, resulting in a greater LA ejection fraction in the presence of similar LA contractile deformation. Conversely, RA volumes were smaller in female athletes, but deformation was similar compared with male athletes. Our findings suggest the presence of sex-specific atrial exercised-induced adaptation.Figure 1.Figure 2.

Diabetic atrial cardiomyopathy can be identified by multiparametric mri MRI associating atrio-ventricular groove adipose tissue and left atrial strain profiles

Abstract Background Epicardial adipose tissue (EAT) is tightly associated with neighboring myocardium with free diffusion between the two tissues of fatty acid, peptides and adipokines. In specific circumstances EAT can favors myocardial remodeling and, for instance, contribute to the risk of atrial fibrillation (AF). Thereby, there is a growing interest for EAT as a biomarker of AF however, which is limited by difficulties of delineation of EAT vs. other paracardial adipose tissues. The atrio-ventricular groove adipose tissue (GEAT) has been proven to be pure epicardial adipose tissue. Purpose We tested the feasibility and value of measuring pure EAT of the atrio-ventricular groove (GEAT) using routine cardiovascular magnetic resonance imaging (CMR) in a cohort of patients with distinct metabolic disorders and studied its correlates to determine a CMR cardiometabolic score. Methods One hundred patients from the METACARDIS cohort (EU FP7) who had MRI, all in sinus rhythm and without overt clinical heart disease, were divided into 4 groups based on distinct metabolic profiles: metabolic syndrome (MSD, n=25), severe obesity (SO, BMI ≥ 35 kg/m2, n=18), type-2 diabetes (T2D, n=42) and healthy controls (n=15). Atrioventricular groove EAT volume was measured from cine SSFP MRI images in four-, three-, two-chamber and short-axis views; atrial EAT volume was measured from four- and two-chamber views. Native T1-mapping values of EAT at the anterior atrioventricular groove excluding the coronary vessels were measured from the MOLLI sequence (basal short-axis slice). Results CMR was performed in 100 patients from the MetaCardis cohort. GEAT volume measured from end-diastolic long axis views was obtained in all patients with a high correlation between GEAT and atrial EAT (r=0.95; P<0.0001). GEAT volume was higher in the 3 groups of patients with metabolic disorders and highest in MSD. Together with age, body mass, fat distribution, GEAT volume allowed to distinguish obese, T2D and MSD from controls. T2D patients were uniquely characterized in CMR by decreased GEAT T1 relaxation and decreased peak longitudinal left atrial strain. We developed a CMR score by logistic regression and Random Forest machine-learning algorithm combining GEAT volume, T1 and peak LA strain that identified T2D patients with an AUC of 0.81 (Se:77%, Spe:80%; 95%-CI 0.72–0.91, p <0.0001). Conclusion The epicardial adipose tissue of the AV groove measured by CMR can be used as the proxy of atrial EAT and, in combination with atrial strain and T1 relaxation, allows the early identification of the atrial cardiomyopathy associated with diabetes. There is diagnostic value of a multiparametric CMR approach for the detection of subclinical atrial cardiomyopathy and potentially to identify patients at risk of atrial fibrillation and stroke.

Contractile asymmetry and survival in patients with left bundle branch abnormality treated with cardiac resynchronization therapy.

Currently, electrical rather than mechanical parameters of delayed left ventricular (LV) activation are used for patient selection for cardiac resynchronization therapy (CRT). However, despite adhering to current guideline-based criteria, about one-third of heart failure (HF) patients fail to derive benefit from CRT. This study sought to investigate the prognostic survival significance of a recently introduced index of contractile asymmetry (ICA) based on the deformation of entire opposing LV walls in the context of selecting patients with HF and left bundle branch abnormality (LBBB) for CRT. We analysed 367 patients with HF and LBBB undergoing CRT (31.6% females, 69 ± 9 years, ischaemic aetiology in 50.7%, LV ejection fraction 27 ± 6%). ICA was calculated using LV strain rate values from curved anatomical M-mode plots of apical 2D echocardiography images. The predictive value of ICA was assessed using Kaplan-Meier analysis and Cox proportional hazards models. During a median follow-up time of 5.54 years, death or cardiac transplantation occurred in 105 (28.6%) cases. Higher baseline ICA values in all apical views, particularly in the two-chamber view (ICA-2ch), were associated with increased event-free survival, and the unadjusted hazard ratio was 0.28 (95% confidence interval 0.18-0.46). Higher ICA-2ch (>0.319 s-1) consistently predicted survival across clinical subgroups and remained significant after covariate adjustment, while the event rate sharply increased in low ICA-2ch cases. Additionally, including ICA-2ch improved the predictive value of the multivariate risk model containing the typical LBBB pattern. Pre-implant ICA suggests a quantitative prognostic threshold for both long-term survival and adverse outcomes following CRT implantation.

Real-time guidance by deep learning of experienced operators to improve the standardization of echocardiographic acquisitions.

Impaired standardization of echocardiograms may increase inter-operator variability. This study aimed to determine whether the real-time guidance of experienced sonographers by deep learning (DL) could improve the standardization of apical recordings. Patients (n = 88) in sinus rhythm referred for echocardiography were included. All participants underwent three examinations, whereof two were performed by sonographers and the third by cardiologists. In the first study period (Period 1), the sonographers were instructed to provide echocardiograms for the analyses of the left ventricular function. Subsequently, after brief training, the DL guidance was used in Period 2 by the sonographer performing the second examination. View standardization was quantified retrospectively by a human expert as the primary endpoint and the DL algorithm as the secondary endpoint. All recordings were scored in rotation and tilt both separately and combined and were categorized as standardized or non-standardized. Sonographers using DL guidance had more standardized acquisitions for the combination of rotation and tilt than sonographers without guidance in both periods (all P ≤ 0.05) when evaluated by the human expert and DL [except for the apical two-chamber (A2C) view by DL evaluation]. When rotation and tilt were analysed individually, A2C and apical long-axis rotation and A2C tilt were significantly improved, and the others were numerically improved when evaluated by the echocardiography expert. Furthermore, all, except for A2C rotation, were significantly improved when evaluated by DL (P < 0.01). Real-time guidance by DL improved the standardization of echocardiographic acquisitions by experienced sonographers. Future studies should evaluate the impact with respect to variability of measurements and when used by less-experienced operators. NCT04580095.

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

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

Evaluation of Subclinical Left Ventricular Systolic Dysfunction By Global Longitudinal Strain Using 2D Speckle Tracking Echocardiography in Angina With Normal Epicardial Coronary Arteries

Background: Global longitudinal strain (GLS), assessed by 2D speckle tracking echocardiography (2D-STE), may offer a valuable non-invasive method to assess subclinical left ventricular (LV) systolic dysfunction in patients with chest pain but normal epicardial coronary arteries. The primary objective of the study was to detect subclinical LV systolic dysfunction by GLS using 2D-STE in patients with angina with normal coronary arteries and conventional echocardiograms at baseline. Methods: This was a comparative case–control study that included patients with complaints of an ischaemic pattern of chest pain despite normal coronary arteries (cases) and healthy individuals (controls). Resting LV systolic function was assessed by transthoracic echocardiography and GLS using 2D-STE analysis. The results of all three planes in GLS (the apical four-chamber, two-chamber, and three-chamber views) were combined in a single ‘bull’s eye’ summary (agreeing with the standard 17-segment model), which presented the analysis of each segment along with a global peak systolic strain value for the LV. Results: The study included 120 participants (60 cases and 60 controls). The normal reference value of the mean GLS in the control group was −19.7 ± 1.84%. GLS assessed by 2D-STE was significantly impaired in patients with angina-like syndrome with normal epicardial coronary arteries (−18.78 ± 1.87 versus −19.7 ± 1.84%; p&lt;0.007) compared with the control group despite preserved LV ejection fraction. In the case group, GLS reduced significantly in eight patients (13.3%) than control group. Conclusion: Patients with angina with normal epicardial coronary arteries are likely to have microvascular disease. GLS assessed by 2D-STE has the potential to improve the value of echocardiography in coronary microvascular disease detection. Despite normal LV ejection fraction, significant impairment of LV global longitudinal systolic function can differentiate a microvascular group of patients from others who have angina with normal coronaries.

Identification of factors associated with progression of left atrial enlargement in patients with atrial fibrillation.

Left atrial (LA) enlargement frequently occurs in atrial fibrillation (AF) patients, and this enlargement is associated with the development of heart failure, thromboembolism, or atrial functional mitral regurgitation (AFMR). AF patients can develop LA enlargement over time, but its progression depends on the individual. So far, the factors that cause progressive LA enlargement in AF patients have thus not been elucidated, so that the aim of this study was to identify the factors associated with the progression of LA enlargement in AF patients. We studied 100 patients with persistent or permanent AF (aged: 67±2 years, 40 females). Echocardiography was performed at baseline and 12 (5-30) months after follow-up. LA size was evaluated as the LA volume index which was calculated with the biplane modified Simpson's method from apical four-and two-chamber views, and then normalized to the body surface area (LAVI). The deterioration of AFMR after follow-up was defined as a deterioration in severity of mitral regurgitation (MR) by a grade of 1 or more. Multivariate regression analysis demonstrated that hypertension (p=.03) was an independently associated parameter of progressive LA enlargement, as was baseline LAVI. In addition, the Kaplan-Meier curve indicated that patients with hypertension tended to show greater deterioration of AFMR after follow-up than those without hypertension (log-rank p=.08). Hypertension proved to be strongly associated with progression of LA enlargement over time in patients with AF. Our findings provide new insights for better management of patients with AF to prevent the development of AFMR.

Assessment of the left ventricular longitudinal deformation failed to detect early changes after the second-stage percutaneous coronary intervention in patients with the acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background Primary intervention in acute coronary syndrome (ACS) is often followed by the second-stage procedure when other atherosclerotic lesions are present. However, there is no data regarding the early effects of such a strategy on left ventricular function. Speckle-tracking echocardiography has been proven a sensitive method in assessing myocardial function. Purpose The study aimed to assess the early results of the second stage of percutaneous coronary intervention (PCI) in patients with ACS. Methods The study group consisted of 61 patients aged from 47 to 92 (mean age 66,3± 9,8) years, 21 women (34,4%) and 40 men (65,6%) who had ACS. Primary treatment involved culprit-lesion only. All pts were optimally treated regarding ischemic heart disease. The second-stage PCI was performed up to four months after ACS. Patients underwent transthoracic echocardiography 48 hours before and after the second-stage PCI. Using automated functional imaging (AFI), we analyzed the global longitudinal strain (GLS) of the left ventricle, GLS in the four-chamber view (GLS-4CH), the two-chamber view (GLS-2CH), and the three-chamber view (GLS-3CH). We also assessed the mean of the peak longitudinal strain of the myocardial segments according to the standard assignment to coronary artery territories, i.e. left anterior descending (LAD), right coronary artery (RCA) and circumflex coronary artery (LCX). Results The following second-stage PCI were performed in the study group: 33 procedures regarding the left anterior descending artery, 15 procedures regarding the left circumflex artery and 13 procedures regarding the right coronary artery. The mean value of the GLS of the left ventricle before the second-stage PCI was slightly reduced compared to the currently established norm (GLS= −16.7%). The second-stage PCI did not result in early changes in the GLS. We also did not observe any significant changes in the mean peak longitudinal strain according to the coronary artery territories (Table 1). Conclusions Despite the proven sensitivity of the deformation imaging technique in assessing left ventricular function, the present work does not show an early effect of the percutaneous coronary intervention on either the global longitudinal strain of the left ventricle or the longitudinal strain of the segments allocated to each coronary arterial territory.

The impact of real-time guiding by deep learning on test-retest variability of automated left ventricular systolic function measurements

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian University of Science and Technology, St. Olavs University Hospital, Central-Norway Health Authority. Background Left ventricular (LV) ejection fraction (EF) and left ventricular volumes are key parameters for characterisation of cardiac function. Test-retest variability of EF and LV end-diastolic volume (EDV) are dependent on image quality and analyses. Foreshortened LV recordings cause inaccuracies in estimation of EF and EDV. Real-time guiding of LV length using deep learning (DL) could improve standardization of image acquisition and reduce variability of automated analyses of EF (auto-EF) and EDV (auto-EDV). Purpose To study the impact of real-time feedback of LV length using a robust deep-learning (DL) software during echocardiography on variability of automated analyses of EF (auto-EF) and EDV (auto-EDV). Methods Patients with mixed cardiac pathology were consecutively included if they were in sinus rhythm without need for contrast. Three consecutive echocardiograms were performed; the first and second by two of three experienced sonographers (Sonographer 1 and 2) and the third (reference) by one of four cardiologists in random order, all affiliated to an EACVI accredited echocardiographic laboratory. All exams included the standard apical views, and the reference exams also included tri-plane recordings of the LV. All measurements were done retrospectively using automated algorithm for measuring. LV volumes were measured in four- and two-chamber views and averaged by the method of discs’ formula. LV EF was calculated as biplane measurements. The coefficients of variation (CV) between sonographers and cardiologists were compared for both LV EF and end-diastolic LV volume from biplane measurements. One-way ANOVA was used to estimate within-patient variation for automated and manual measurements. Results A total of 47 patients (47% women) were included with mean (SD) age 64 (15) years. There was no significant difference in CV for neither auto-EF nor auto-EDV using the DL tool (Table) compared to standard care. Manual and automated measurements of LV volumes and EF correlated well with R 0.91 and R 0.74, respectively (only data for EF shown in the figure). Conclusion Real-time guiding did not significantly reduce variation of automated analyses of LV volumes and EF when used by experienced sonographers. Further studies are needed to evaluate the effect of real-time guiding to optimize LV acquisition in inexperienced users.

Automated evaluation of the left-sided heart volumes using machine learning during stress echocardiography: a multicenter stress echo 2030 study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): HORIZON. Introduction Stress echocardiography (SE) is a recognized method for risk assessment and detection of coronary artery disease. Although left atrial (LA) and left ventricle (LV) volumes provide valuable information during SE, the time-consuming manual tracings of these structures and operator-dependent accuracy remain significant limitations in analyzing and interpreting SE that might be overcome by automated evaluation. Purpose To assess the potential of an automated machine learning (ML) system for the volumetric evaluation of left-sided heart volumes during SE. Methods The study enrolled 218 participants from five recruiting centers who underwent SE (in most cases, dipyridamole SE). Imaging data were acquired in DICOM format and anonymized for further processing. The studies were evaluated by an expert cardiologist trained in SE evaluation who selected apical four-chamber (4Ch) and two-chamber (2Ch) view images during stress and rest phases an marked end-systolic (ES) and end-diastolic (ED) frames and traced endocardial borders for LA (in ES) and LV (in ED and ES). The same frames were then processed by a transformer neural network trained on a separate set of images. LA volume (LAV), LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) was calculated in 4Ch and 2Ch views during rest and at stress phases. Each evaluator (cardiologist and ML model) was blinded from each other's measurements. All of the tracings and automated measurements were performed on the same platform. Results Comparison between evaluators by Student's paired t-test showed the best agreement between LAV (4Ch) and LVESV (2Ch) during the rest phase and LVEDV (4Ch and 2Ch) during the stress phase (p&amp;gt;0.05). Other volumetric measurements tended to be slightly higher (except LVEDVs at rest) and LVEF lower assessed by ML than by cardiologists. Pearson's correlation analysis demonstrated strong correlations between the ML model and cardiologist for LAVs (4Ch LAV r=0.94, p&amp;lt;0.001 and r=0.93, p&amp;lt;0.001, 2Ch LAV r=0.91, p&amp;lt;0.001 and r=0.88, p&amp;lt;0.001 at rest and stress, respectively), and LV volumes (4Ch LVEDV r=0.86, p&amp;lt;0.001 and r=0.84, p&amp;lt;0.001, 2Ch LVEDV r=0.82, p&amp;lt;0.001 and r=0.93, p&amp;lt;0.001, 4Ch LVESV r=0.82, p&amp;lt;0.001 and r=0.83, p&amp;lt;0.001, 2Ch LVESV r=0.86, p&amp;lt;0.001 and r=0.82, p&amp;lt;0.001 at rest and stress, respectively), and moderate correlations for LVEF measurements during rest and stress phases. The strongest correlations between raters and the smallest root mean squared errors (RMSEs) were for LAV measurements. Conclusions This multicenter study showed the effectiveness of using ML to produce left-sided heart measurements during SE. There was a tendency for higher volumes assessed by ML, demonstrating the need for additional standardization of SE evaluation for more precise accuracy. However, correlations between the ML model and cardiologists' measurements for left-sided heart volumes were strong during the rest and the stress phases.