Journal: J Am Soc Echocardiogr

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Abstract

Association of global cardiac calcification with atrial fibrillation and recurrent stroke in patients with embolic stroke of undetermined source.

Li TY, Yeo LL, Ho JS, Leow AS, ... Yong-Qiang Tan B, Sia CH
Background
Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke as well as atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for assessment of patients with embolic strokes of undetermined source (ESUS). This study aims to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS.
Methods
This study identified and evaluated 181 consecutive stroke patients diagnosed with ESUS. They were followed-up for new-onset AF and ischemic stroke recurrence for a median duration of 2.1 years. Various echocardiographic cardiac calcification scores were assessed on the transthoracic echocardiogram performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (a) Global Cardiac Calcium Score (GCCS), (b) Echocardiographic Calcium Score (eCS), (c) Echocardiographic calcification score (echo-CCS), (d) Echocardiographic Composite Cardiac Calcium Score (E-CCCS), and (e) Total Heart Calcification (THC) score. Only 2 out of 5 scoring schemes, namely GCCS and eCG, quantified the cardiac calcium burden.
Results
Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in ESUS patients. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF.
Conclusion
Higher cardiac calcification scores measured using the GCCS and eCS are independently associated with AF detection and recurrent ischemic stroke in ESUS patients and can be useful markers for further risk stratification in ESUS patients.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 15 Apr 2021; epub ahead of print
Li TY, Yeo LL, Ho JS, Leow AS, ... Yong-Qiang Tan B, Sia CH
J Am Soc Echocardiogr: 15 Apr 2021; epub ahead of print | PMID: 33872703
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Abstract

State of the Art: Transcatheter Edge-to-Edge Repair for Complex Mitral Regurgitation.

Flint N, Price MJ, Little SH, Mackensen GB, ... Makar M, Siegel RJ
Transcatheter edge-to-edge mitral valve repair has revolutionized the treatment of primary and secondary mitral regurgitation. The landmark EVEREST (Endovascular Valve Edge-to-Edge Repair Study) and COAPT (Clinical Outcomes Assessment of the MitraClip Percutaneous Therapy for High Surgical Risk Patients) trials included only clinically stable patients with favorable mitral valve anatomy for edge-to-edge repair. However, since its initial commercial approval in the US, growing operator experience, device iterations, and improvements in intraprocedural imaging have led to an expansion in the utilization of transcatheter edge-to-edge repair to more complex mitral valve pathologies and clinical scenarios, many of which were previously considered a contraindication for the procedure. As prohibitive surgical risk patients are often older and present with complex mitral valve disease, knowledge of the potential effectiveness, versatility and technical approach to a broad range of anatomy is clinically relevant. This review examines the current experience with mitral valve transcatheter edge-to-edge repair in various pathologies and scenarios that go well beyond the EVEREST II trial inclusion criteria.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 15 Apr 2021; epub ahead of print
Flint N, Price MJ, Little SH, Mackensen GB, ... Makar M, Siegel RJ
J Am Soc Echocardiogr: 15 Apr 2021; epub ahead of print | PMID: 33872701
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Abstract

Prognostic Value of Peak Exercise Systolic Pulmonary Arterial Pressure in Asymptomatic Primary Mitral Valve Regurgitation.

Arangalage D, Cattan L, Eugène M, Cimadevilla C, ... Vahanian A, Messika-Zeitoun D
Background
The contribution of exercise echocardiography in primary asymptomatic mitral regurgitation (MR) remains debated. We aimed to gain evidence regarding its usefulness in this setting, and investigate the prognostic value of peak exercise systolic pulmonary artery pressure (SPAP).
Methods
We identified 177 patients (56±13 years, 69% males) with moderate-to-severe (3+)/severe (4+) degenerative MR and preserved left ventricular ejection fraction (LVEF), in sinus rhythm, referred for a clinically indicated exercise echocardiography. Our end-point, MR-related events, was a composite of all-cause death or occurrence of symptoms, heart failure, atrial fibrillation, LVEF<60%, LV end-systolic diameter≥45mm or resting SPAP>50mmHg.
Results
At rest, effective regurgitant orifice area was 48±16mm2, regurgitant volume 74±26ml, SPAP 32±7mmHg, and MR severe in 138 patients (78%). The peak exercise SPAP was 55±10mmHg. Exercise test positivity motivated surgery in 26 patients, 11 underwent prophylactic surgery, 10 were lost to follow-up and 130 included for the outcome analysis. During a follow-up of 19±7 months, 31 MR-related events (24%) were reported. Peak exercise SPAP was predictive of outcome in univariate analysis (p=0.01) and after adjustment for age, gender, MR severity, and resting SPAP (p<0.05). A peak exercise SPAP≥50mmHg was associated with worse event-free survival (HR=5.24; 95%CI:1.77-15.53; p=0.003), but not the threshold of ≥60mmHg proposed in previous guidelines (HR=1.70; 95%CI:0.71-4.03; p=0.24).
Conclusions
Our findings support the use of exercise echocardiography for risk stratification in asymptomatic primary MR and suggest a lower peak exercise SPAP threshold (50 mmHg) than previously recommended to define the timing of intervention. Prospective studies are needed to confirm these findings.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 15 Apr 2021; epub ahead of print
Arangalage D, Cattan L, Eugène M, Cimadevilla C, ... Vahanian A, Messika-Zeitoun D
J Am Soc Echocardiogr: 15 Apr 2021; epub ahead of print | PMID: 33872700
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Abstract

Mitral Annular Calcification and Calcific Mitral Stenosis: Role of Echocardiography in Hemodynamic Assessment and Management.

Silbiger JJ
As the life expectancy of the population continues to increase, mitral annular calcification (MAC) has emerged as an important cause of mitral stenosis (MS), commonly referred to as calcific or degenerative MS. MAC results in valvular stenosis when calcification extends into the base of the mitral leaflet(s) and displaces the mitral valve hinge point(s) into the LV inlet. Echocardiographic determination of mitral vale area is fraught with difficulties and often precludes using planimetry or the Hatle formula. Given the numerous confounders which affect transmitral flow in calcific MS, evaluation of lesion severity should employ flow-independent methods such as the continuity equation and the mitral valve dimensionless index. In light of the significant risks entailed there is little enthusiasm for mitral valve replacement in patients with calcific MS. Transcatheter mitral valve replacement is generally offered on a compassionate use basis to patients deemed to be at high surgical risk.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 11 Apr 2021; epub ahead of print
Silbiger JJ
J Am Soc Echocardiogr: 11 Apr 2021; epub ahead of print | PMID: 33857624
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Abstract

Left Atrial Strain Associated with Functional Recovery in Patients Receiving Optimal Treatment for Heart Failure.

Torii Y, Kusunose K, Hirata Y, Nishio S, ... Wakatsuki T, Sata M
Background
Heart failure with recovered ejection fraction (HFrecEF) has been reported in several previous studies to have a better prognosis than HF with reduced EF (HFrEF). However, the factors associated with HFrecEF have not been identified. We hypothesized that left atrial (LA) strain could help to identify patients with recovered EF among cases of HF with low EF on admission.
Methods
We enrolled 100 consecutive patients hospitalized for the first time due to new-onset HF. Patients were clinically diagnosed with HFrEF on admission (LVEF <40%) and underwent optimal treatment for HF. Twenty-eight patients improved to HFrecEF during 6 months of follow-up.
Results
Regarding clinical background, there were significantly more females and a lower rate of atrial fibrillation in the HFrecEF group than in the HFrEF group. In the multivariable logistic regression analysis, LA strain was an independent predictor of HFrecEF, even after adjustment for gender and LVEF (OR: 4.06, 95% CI: 2.04-8.07, P < 0.001). A cutoff value of 10.8% for LA strain showed high sensitivity (96%) and specificity (82%) in identifying HFrecEF in HF patients presenting with low EF on admission. During a follow-up period of 24 ± 13 months, 31 patients (31%) had cardiovascular death or readmission due to HF. Patients with reduced LA strain (less than 10.8%) had significantly shorter event-free survival than preserved LA strain (P = 0.02).
Conclusion
LA strain is a useful indicator for predicting HFrecEF and should be considered as a routine measurement in patients with HFrEF on admission.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 10 Apr 2021; epub ahead of print
Torii Y, Kusunose K, Hirata Y, Nishio S, ... Wakatsuki T, Sata M
J Am Soc Echocardiogr: 10 Apr 2021; epub ahead of print | PMID: 33852960
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Abstract

Left Ventricular Global Longitudinal Strain as a Predictor of Outcomes in Heart Failure Patients with Secondary Mitral Regurgitation: The COAPT Trial.

Medvedofsky D, Pio SM, Weissman NJ, Namazi F, ... Asch FM, COAPT Investigators
Background
Left ventricular (LV) global longitudinal strain (GLS) is a sensitive marker of LV function and may help identify patients with heart failure (HF) and secondary mitral regurgitation (SMR) who would have a better prognosis and are more likely to benefit from edge-to-edge transcatheter mitral valve repair (TMVr) with the MitraClip. We sought to assess the prognostic utility of baseline LVGLS during 2-year follow-up of HF patients with SMR enrolled in the COAPT trial.
Methods
Symptomatic HF patients with moderate-to-severe or severe SMR who remained symptomatic despite maximally-tolerated guideline directed medical therapy (GDMT) were randomized to TMVr plus GDMT or GDMT alone. Speckle tracking-derived LVGLS from baseline echocardiograms was obtained in 565 patients and categorized by tertiles. Death and HF hospitalization (HFH) at 2-year follow-up were the principal outcomes of interest.
Results
Patients with better baseline LVGLS had higher blood pressure, greater LV ejection fraction and stroke volume, lower levels of B-type natriuretic peptide and smaller LV size. No significant difference in outcomes at 2-year follow-up were noted according to LVGLS. However, the rate of death or HFH between 10 and 24 months was lower in patients with better LVGLS (p=0.03), with no differences before 10 months. There was no interaction between GLS tertiles and treatment group with respect to 2-year clinical outcomes.
Conclusions
Baseline LVGLS did not predict death or HFH throughout 2-year follow-up, but it did predict outcomes after 10 months. The benefit of TMVr over GDMT alone was consistent in all sub-groups irrespective of baseline LVGLS.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 08 Apr 2021; epub ahead of print
Medvedofsky D, Pio SM, Weissman NJ, Namazi F, ... Asch FM, COAPT Investigators
J Am Soc Echocardiogr: 08 Apr 2021; epub ahead of print | PMID: 33845158
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Abstract

Ratio between vena contracta width and tricuspid annular diameter: prognostic value in secondary tricuspid regurgitation.

Fortuni F, Dietz MF, Prihadi EA, van der Bijl P, ... Delgado V, Marsan NA
Background
Conventional approaches for the assessment of secondary tricuspid regurgitation (STR) severity do not correct for right heart dimensions. We hypothesized that STR severity can be proportional or disproportional to the dilation of the tricuspid annulus (TA) and we investigated the prognostic impact of this novel definition.
Methods
A total of 334 patients with moderate-to-severe STR and preserved left ventricular systolic function were included. The ratio between vena contracta (VC) width and TA diameter was calculated. The cut-off value for VC/TA ratio associated with increased risk of all-cause death was identified with a spline curve analysis.
Results
The cut-off value of VC/TA ratio associated with a mortality excess was 0.24 and 165 (49%) patients had a VC/TA ratio ≥0.24. Compared to those with VC/TA ratio <0.24, patients with VC/TA ratio ≥0.24 had higher prevalence of moderate-to-severe mitral regurgitation, higher pulmonary pressures and were more frequently treated with diuretics. During a median follow-up of 62 (28-101) months, 128 (38%) patients died. The cumulative 5-year survival rate was significantly worse in patients with VC/TA ratio ≥0.24 (55%vs71%, P=0.001). VC/TA ratio ≥0.24 was independently associated with poor outcomes on multivariable analysis (hazard-ratio 1.567; 95%CI 1.044-2.352; P=0.030) together with coronary artery disease, renal impairment, right ventricular systolic function (either evaluated with tricuspid-annular-plane-systolic-excursion or RV free-wall strain), and pulmonary pressures.
Conclusions
VC/TA ratio ≥0.24 is independently associated with poor prognosis in patients with STR. This parameter may be considered as a marker of disproportionate STR and could improve risk stratification and clinical decision making.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 07 Apr 2021; epub ahead of print
Fortuni F, Dietz MF, Prihadi EA, van der Bijl P, ... Delgado V, Marsan NA
J Am Soc Echocardiogr: 07 Apr 2021; epub ahead of print | PMID: 33839257
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Abstract

Determining which hospitalized COVID-19 patients require an urgent echocardiogram.

Yuan N, Wu S, Rader F, Siegel RJ
Background
Patients hospitalized with COVID-19 infection often have abnormal transthoracic echocardiogram (TTE) findings. However, while not all TTE abnormalities result in changes in clinical management, performing TTEs in recently infected patients increases disease transmission risks. It remains unknown whether common biomarker tests, such as troponin and B-type natriuretic peptide (BNP), can help distinguish in which COVID-19 patients a TTE may be safely delayed until infection risks subside.
Method
Using electronic health records data and chart review, we retrospectively studied all patients hospitalized with COVID-19 infection at our multi-site healthcare system from 2/27/2020-1/15/2021 who underwent a TTE within 14 days of their first positive COVID-19 test and had a BNP and troponin measured before or within 7 days of TTE. The primary outcome was presence of ≥1 urgent echocardiographic finding defined as left ventricular ejection fraction ≤35%, wall motion score index ≥1.5, ≥moderate right ventricular dysfunction, ≥moderate pericardial effusion, intracardiac thrombus, pulmonary artery systolic pressure >50mmHg, or ≥moderate-severe valvular disease. We conducted stepwise logistic regression to determine biomarkers and comorbidities associated with the outcome. We evaluated the performance of a rule for classifying TTEs using troponin and BNP.
Results
We included 434 hospitalized and 151 ICU COVID-19 patients. Urgent TTE findings were present in 105 (24.2%) patients. Troponin and BNP were abnormal in 311 (71.7%). Heart failure (OR (95%CI) 5.41 (2.61-11.68)), troponin >0.04ng/mL (4.40 (2.05-10.05)), BNP >100pg/mL (5.85 (2.35-16.09)) remained significant predictors of urgent TTE findings after stepwise selection. 95.1% of all patients and 91.3% of ICU patients with normal troponin and BNP had no urgent TTE findings.
Conclusions
Troponin and BNP were highly associated with urgent echocardiographic findings and may be used in triaging algorithms for determining which patients may safely delay their TTE studies until after their peak infectious window has passed.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 31 Mar 2021; epub ahead of print
Yuan N, Wu S, Rader F, Siegel RJ
J Am Soc Echocardiogr: 31 Mar 2021; epub ahead of print | PMID: 33812952
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Abstract

Early Role of the Atrial-Level Communication in Premature Infants with Patent Ductus Arteriosus.

Rios DR, Martins FF, El-Khuffash A, Weisz DE, Giesinger RE, McNamara PJ
Background
High-volume systemic-to-pulmonary ductus arteriosus shunts in premature infants are associated with adverse neonatal outcomes. The role of an atrial communication (AC) in modulating the effects of a presumed hemodynamically significant patent ductus arteriosus (PDA) is poorly studied. The objective of this study was to characterize the relationship between early AC and echocardiographic indices of PDA shunt volume and clinical neonatal outcomes.
Methods
A retrospective review of preterm infants (born at <32 weeks\' gestation) who underwent echocardiography in the first postnatal week was performed. The cohort was divided into four groups on the basis of presence of a presumed hemodynamically significant PDA (≥1.5 vs <1.5 mm) and AC size (≤1 vs >1 mm), and echocardiographic measures of PDA shunt volume were then compared. Clinical outcomes, including chronic lung disease and intraventricular hemorrhage, were also compared among all four groups.
Results
A total of 199 preterm infants (mean birth weight, 928 ± 632 g; mean gestational age, 26.6 ± 1.5 weeks) were identified; 159 infants had PDAs ≥ 1.5 mm, of whom 52 had ACs ≤ 1 mm and 107 had ACs > 1 mm. The remaining 40 infants had PDAs < 1.5 mm, of whom 23 had ACs ≤ 1 mm and 17 had ACs > 1 mm. Infants with PDAs ≥ 1.5 mm and ACs > 1 mm had higher pulmonary vein D-wave velocities (P < .05), higher left ventricular output (P < .005), higher PDA scores (P < .001), and increased rates of reversed diastolic flow in the descending aorta (P < .001), celiac artery (P < .001), and middle cerebral artery (P < .001) than infants with either PDAs < 1.5 mm or PDAs ≥ 1.5 mm and ACs ≤ 1 mm. There was no difference in the incidence of intraventricular hemorrhage, but infants with PDAs ≥ 1.5 mm and ACs > 1 mm had a higher risk for a composite outcome of chronic lung disease or death before hospital discharge (P < .05).
Conclusions
Echocardiographic evidence of ACs > 1 mm in patients with PDAs ≥ 1.5 mm during the first postnatal week may be a marker of a more pathologic hemodynamically significant PDA in premature infants. Future investigations should evaluate if early identification and treatment of patients with both high-volume PDAs and larger atrial-level communications may help mitigate adverse outcomes, such as chronic lung disease or death, in this high-risk patient population.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:423-432.e1
Rios DR, Martins FF, El-Khuffash A, Weisz DE, Giesinger RE, McNamara PJ
J Am Soc Echocardiogr: 30 Mar 2021; 34:423-432.e1 | PMID: 33227390
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Abstract

Fetal Vascular Rings and Pulmonary Slings: Strategies for Two- and Three-Dimensional Echocardiographic Diagnosis.

Wang Y, Zhang Y
Fetal aortic arch anomalies and pulmonary slings can be difficult to accurately diagnose but have important clinical implications related to vascular rings, congenital heart disease, and chromosomal anomalies. In this article, the authors briefly review the embryology and development of the fetal arch to facilitate understanding of its diverse variants. Two-dimensional echocardiographic characteristics are summarized for each type of these malformations to propose a strategy for fetal diagnosis. The added benefits of three-dimensional echocardiography with spatiotemporal image correlation are also shown. Finally, the authors propose a strategy for volume acquisition and postanalysis to spur postanalysis clinical use of this technology.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:336-351
Wang Y, Zhang Y
J Am Soc Echocardiogr: 30 Mar 2021; 34:336-351 | PMID: 33166631
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Abstract

Age-Related Development of Cardiac Remodeling and Dysfunction in Young Black and White Adults: The Coronary Artery Risk Development in Young Adults Study.

Perak AM, Khan SS, Colangelo LA, Gidding SS, ... Lima JAC, Lloyd-Jones DM
Background
Little is known about the timing of preclinical heart failure (HF) development, particularly among blacks. The primary aims of this study were to delineate age-related left ventricular (LV) structure and function evolution in a biracial cohort and to test the hypothesis that young-adult LV parameters within normative ranges would be associated with incident stage B-defining LV abnormalities over 25 years, independent of cumulative risk factor burden.
Methods
Data from the Coronary Artery Risk Development in Young Adults study were analyzed. Participants (n = 2,833) had a mean baseline age of 30.1 years; 45% were black, and 56% were women. Generalized estimating equation logistic regression was used to estimate age-related probabilities of stage B LV abnormalities (remodeling, hypertrophy, or dysfunction) and logistic regression to examine risk factor-adjusted associations between baseline LV parameters and incident abnormalities. Cox regression was used to assess whether baseline LV parameters associated with incident stage B LV abnormalities were also associated with incident clinical (stage C/D) HF events over >25 years\' follow-up.
Results
Probabilities of stage B LV abnormalities at ages 25 and 60 years were 10.5% (95% CI, 9.4%-11.8%) and 45.0% (95% CI, 42.0%-48.1%), with significant race-sex disparities (e.g., at age 60, black men 52.7% [95% CI, 44.9%-60.3%], black women 59.4% [95% CI, 53.6%-65.0%], white men 39.1% [95% CI, 33.4%-45.0%], and white women 39.1% [95% CI, 33.9%-44.6%]). Over 25 years, baseline LV end-systolic dimension indexed to height was associated with incident systolic dysfunction (adjusted odds ratio per 1 SD higher, 2.56; 95% CI, 1.87-3.52), eccentric hypertrophy (1.34; 95% CI, 1.02-1.75), concentric hypertrophy (0.69; 95% CI, 0.51-0.91), and concentric remodeling (0.68; 95% CI, 0.58-0.79); baseline LV mass indexed to height2.7 was associated with incident eccentric hypertrophy (1.70; 95% CI, 1.25-2.32]), concentric hypertrophy (1.63; 95% CI, 1.19-2.24), and diastolic dysfunction (1.24; 95% CI, 1.01-1.52). Among the entire cohort with baseline echocardiographic data available (n = 4,097; 72 HF events), LV end-systolic dimension indexed to height and LV mass indexed to height2.7 were significantly associated with incident clinical HF (adjusted hazard ratios per 1 SD higher, 1.56 [95% CI, 1.26-1.93] and 1.42 [95% CI, 1.14-1.75], respectively).
Conclusions
Stage B LV abnormalities and related racial disparities were present in young adulthood, increased with age, and were associated with baseline variation in indexed LV end-systolic dimension and mass. Baseline indexed LV end-systolic dimension and mass were also associated with incident clinical HF. Efforts to prevent the LV abnormalities underlying clinical HF should start from a young age.

Copyright © 2020 American Society of Echocardiography. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:388-400
Perak AM, Khan SS, Colangelo LA, Gidding SS, ... Lima JAC, Lloyd-Jones DM
J Am Soc Echocardiogr: 30 Mar 2021; 34:388-400 | PMID: 33212181
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Abstract

Basal Segmental Longitudinal Strain: A Marker of Subclinical Myocardial Involvement in Anderson-Fabry Disease.

Zada M, Lo Q, Boyd AC, Bradley S, ... Tchan MC, Thomas L
Background
Cardiac involvement in Anderson-Fabry disease (AFD) is associated with increased left ventricular (LV) wall thickness. The aim of this study was to evaluate if two-dimensional global and regional strain in patients with AFD can identify early myocardial involvement (when LV wall thickness and function are normal). Additionally, the association of altered strain with adverse cardiovascular events was evaluated.
Methods
In a retrospective cross-sectional study, 43 patients with AFD, before enzyme replacement therapy (mean age, 44 ± 12 years; 58.1% men), were compared with age- and gender-matched healthy control subjects. The mean follow-up duration among patients with AFD for major adverse cardiovascular events (MACE) was 82 months.
Results
LV ejection fraction was similar between groups (patients with AFD vs control subjects, 61 ± 8% vs 61 ± 6%; P = .89). However, global longitudinal strain (LS) was impaired in patients with AFD compared with control subjects (-16.5 ± 3.8% vs -20.2 ± 1.7%, P < .001), with greater impairment in patients with AFD with increased LV wall thickness (-15.4 ± 3.9% vs -18.7 ± 2.3%, P < .006). Additionally, LS was most impaired in the basal segments in patients with AFD (-14.8 ± 3.7% vs -20.3 ± 1.1%, P < .001). MACE occurred in 19 of 43 patients (four women, 15 men), and Kaplan-Meier analysis demonstrated that MACE were associated with impaired basal LS.
Conclusions
In patients with AFD, altered basal LS is present even in those with normal LV wall thickness and is associated with MACE. Therefore, basal LS should be considered when screening for cardiac involvement in AFD, particularly in female patients with AFD with normal LV wall thickness.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:405-413.e2
Zada M, Lo Q, Boyd AC, Bradley S, ... Tchan MC, Thomas L
J Am Soc Echocardiogr: 30 Mar 2021; 34:405-413.e2 | PMID: 33242609
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Abstract

Effect of Intermittent High-Mechanical Index Impulses on Left Ventricular Strain.

Albulushi A, Olson J, Xie F, Qian L, ... Aboeata A, Porter TR
Background
Intermittent high-mechanical index (MI) impulses from a transthoracic ultrasound transducer are recommended for regional wall motion analysis and assessment of myocardial perfusion following intravenous administration of ultrasound enhancing agents (UEAs). High-MI impulses (>1.0) applied in this setting have also been shown to increase microvascular blood flow through a purinergic signaling pathway, but their effects on left ventricular (LV) myocardial function are unknown. Therefore, the aim of this study was to investigate the effect of transthoracic intermittent high-MI impulses during intravenous UEA infusion in patients with normal and abnormal resting systolic function.
Methods
Fifty patients referred for echocardiography to evaluate LV systolic function during continuous infusion of UEAs (Definity 3% infusion) were prospectively assigned to low-MI (<0.2) imaging alone (group 1) or low-MI (<0.2) imaging with intermittent high-MI impulses (five frames, 1.8 MHz, MI = 1.0-1.2) applied at least two times in each apical window to clear myocardial contrast (group 2). Global longitudinal strain (GLS) measurements were obtained at baseline before UEA administration and at 5-min intervals up to 10-min after infusion completion.
Results
There were no differences between groups with respect to age, gender, resting GLS, biplane LV ejection fraction, or cardiac risk factors. Resting GLS in group 1 was -15.5 ± 5.2% before UEA infusion and -15.5 ± 5.4% at 10 min after UEA infusion. In comparison, GLS increased in group 2 (-15.3 ± 5.0 before infusion and -16.8 ± 4.8% at 10 min, P < .00001). Improvements in GLS were seen in patients with normal and abnormal systolic function. Regional analysis demonstrated that the increase in strain in patients with abnormal LV ejection fractions was primarily in the apical segments (-12.0 ± 2.7% before infusion and -13.4 ± 3.4% at 10 min, P = .001).
Conclusions
High-MI impulses during infusion of a commercially available contrast agent can improve LV systolic function and may have therapeutic effect in patients with LV dysfunction.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:370-376
Albulushi A, Olson J, Xie F, Qian L, ... Aboeata A, Porter TR
J Am Soc Echocardiogr: 30 Mar 2021; 34:370-376 | PMID: 33253816
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Abstract

Association of Left Ventricular Volume in Predicting Clinical Outcomes in Patients with Aortic Regurgitation.

Anand V, Yang L, Luis SA, Padang R, ... Nishimura RA, Pellikka PA
Background
Aortic regurgitation (AR) is a common valvular lesion associated with increased mortality once the left ventricle enlarges significantly or develops systolic dysfunction (ejection fraction < 50%). Valve guidelines recommend aortic valve repair or replacement (AVR) for left ventricular (LV) linear end-systolic dimension ≥ 50 mm or end-diastolic dimension ≥ 65 mm. However, chamber quantification guidelines recommend using LV volume for LV size determination because linear measurements may not accurately reflect LV remodeling. The aim of this study was to evaluate the correlation of LV volumes with linear dimensions, interobserver variability in the estimation of volumes, and the association of volumes with outcomes in patients with AR.
Methods
A total of 1,100 consecutive patients with chronic moderate to severe and severe AR on echocardiography between 2004 and 2019 were retrospectively analyzed. The modified Simpson disk summation method was used for LV volume estimation. The primary outcome was all-cause mortality; the secondary outcome was mortality censored at AVR.
Results
Patients\' age was 60 ± 17 years, and 198 were women (18%). Volumes were measured using the biplane method in 939 patients (85%) and the monoplane method in 161 (15%); end-systolic volume was normal in 169 (11%). Correlations between volumes and linear dimensions were 0.5 for end-diastolic volume and 0.6 for end-systolic volume. At median follow-up of 5.4 years (interquartile range, 2.4-10.0 years), 216 patients had died and 539 had undergone AVR. Indexed LV end-systolic volume (iLVESV) and indexed left ventricular end-systolic dimension were both associated with mortality and symptoms, but the association of iLVESV was stronger. iLVESV, age, male gender, Charlson comorbidity index, New York Heart Association functional class III or IV, and time-dependent AVR were independently associated with all-cause mortality. Interobserver variability in the estimation of LV volumes in 200 patients included intraclass coefficients of 0.94 (95% CI, 0.92-0.95) for end-diastolic volume and 0.88 (95% CI, 0.78-0.93) for end-systolic volume. Patients with iLVESV ≥ 45 mL/m2 had lower survival and a higher prevalence of symptoms than those with volumes < 45 mL/m2.
Conclusions
Echocardiographic LV volume assessment had good reproducibility in patients with moderate to severe and severe AR. The correlation between linear dimensions and volumes was limited. Both iLVESV and indexed left ventricular end-systolic dimension were associated with worse outcomes, but the association of iLVESV was stronger. iLVESV ≥ 45 mL/m2 was associated with worse outcomes.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:352-359
Anand V, Yang L, Luis SA, Padang R, ... Nishimura RA, Pellikka PA
J Am Soc Echocardiogr: 30 Mar 2021; 34:352-359 | PMID: 33253815
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Abstract

Echocardiographic Molecular Imaging of the Effect of Anticytokine Therapy for Atherosclerosis.

Shentu W, Ozawa K, Nguyen TA, Wu MD, ... López JA, Lindner JR
Background
Echocardiographic molecular imaging techniques are beginning to be applied to evaluate preclinical efficacy of new drugs. In a large clinical trial, anti-interleukin-1β (IL-1β) immunotherapy reduced atherosclerotic events, yet treatment effects were modest, and the mechanisms of action were not fully elucidated. We tested the hypothesis that echocardiographic molecular imaging can assess changes in vascular thromboinflammatory status in response to anti-IL-1β therapy.
Methods
In wild-type and atherosclerotic mice deficient for the low-density lipoprotein-receptor and Apobec-1, closed-chest myocardial infarction (MI) was performed to mimic high-risk clinical cohorts. Control animals had sham surgery. Post-MI animals were randomized to either no therapy or anti-IL-1β immunotherapy, which was continued weekly. At post-MI day 3 or 21, in vivo ultrasound molecular imaging of aortic VCAM-1, P-selectin, von Willebrand factor A1-domain, and platelet GPIbα in the thoracic aorta was performed. Aortic histology and NF-κB activity were assessed in atherosclerotic mice.
Results
In both atherosclerotic and wild-type mice, MI produced a several-fold increase (P < .05) in aortic molecular signals for P-selectin, VCAM-1, von Willebrand factor, and GPIbα. In atherosclerotic mice, signal remained elevated at day 21. Anti-IL-1β therapy completely abolished the post-MI increase in signal for all endothelial targets (P < .05 vs nontreated) at day 3 and 21. In atherosclerotic mice, MI triggered an increase in aortic plaque growth and macrophage content, a decrease in plaque collagen, and elevated aortic NF-κB (P < .05 for all changes). All of these remote plaque adverse changes were inhibited by anti-IL-1β therapy.
Conclusions
Echocardiographic molecular imaging of the vascular endothelium can quantify the beneficial effects of therapies designed to suppress the proatherosclerotic arterial thromboinflammatory effects of alarmins such as IL-1β. This approach could potentially be used to evaluate the biologic variables that influence response in preclinical studies, and possibly to select patients most likely to benefit from therapy.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:433-442.e3
Shentu W, Ozawa K, Nguyen TA, Wu MD, ... López JA, Lindner JR
J Am Soc Echocardiogr: 30 Mar 2021; 34:433-442.e3 | PMID: 33253812
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Abstract

Left Ventricular Remodeling and Its Progression in Asymptomatic Patients with Chronic Aortic Regurgitation: Evaluation by Speckle-Tracking Echocardiography.

Zeng Q, Wang S, Zhang L, Li Y, ... Li H, Xie M
Background
Progression of chronic aortic regurgitation (CAR) is insidious, and management is challenging. The primary aim of this study was to evaluate left ventricular (LV) remodeling and its progression in asymptomatic patients with CAR and preserved LV ejection fraction by three-dimensional speckle-tracking echocardiography (STE). The secondary aim was to identify the effect of management strategies on LV remodeling in severe CAR.
Methods
One hundred thirty-five patients and 41 control subjects were enrolled. Patients were divided according to regurgitation degree: mild (n = 48), moderate (n = 40), or severe (n = 47). Routine follow-up was not possible in 13 patients in the severe CAR group. The remaining 34 patients were divided into three groups on the basis of treatment (surgical, n = 13; drug, n = 11; and untreated, n = 10) and followed for 2.1 ± 0.37 years. All subjects underwent three-dimensional STE at baseline and follow-up, while 20 patients with CAR also underwent baseline two-dimensional STE and feature-tracking cardiovascular magnetic resonance imaging. Volumetric and strain parameters were acquired.
Results
Compared with global circumferential strain derived from two-dimensional STE and feature-tracking cardiovascular magnetic resonance imaging, three-dimensional global circumferential strain was largest (P < .001); however, no significant differences in volumetric parameters, global longitudinal strain (GLS), and global radial strain (GRS) were identified at baseline. GLS, GRS, torsion, apical rotation, and twist were worse in the severe group (P < .05). During follow-up, LV volumetric indexes and sphericity indexes increased, while global longitudinal strain, apical rotation, and twist worsened (P < .05) in the untreated group. In the surgical group, LV volumetric and sphericity indexes decreased, while GLS and GRS improved (P < .05). In the drug group, LV volumetric indexes increased, while LV ejection fraction, GLS, and GRS worsened (P < .05).
Conclusions
Three-dimensional STE may be a reliable tool to monitor the progression of ventricular remodeling in CAR. Drug therapy may not prevent progressive ventricular dilatation and myocardial depression.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:360-369
Zeng Q, Wang S, Zhang L, Li Y, ... Li H, Xie M
J Am Soc Echocardiogr: 30 Mar 2021; 34:360-369 | PMID: 33278525
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Abstract

Echocardiographic Predictors of Successful Extracorporeal Membrane Oxygenation Weaning After Refractory Cardiogenic Shock.

Kim D, Jang WJ, Park TK, Cho YH, ... Jeon ES, Yang JH
Background
Limited data are available regarding echocardiographic predictors for successful weaning from venoarterial (VA) extracorporeal membrane oxygenation (ECMO). We sought to determine whether echocardiographic parameters during ECMO flow study could predict successful weaning from ECMO.
Methods
A total of 92 ECMO patients from a multicenter ECMO registry underwent VA-ECMO flow study with transthoracic echocardiography before a weaning trial. During VA-ECMO flow study, flow was decreased by 30%-50% of the initial flow for 15 minutes, and echocardiography was performed both at baseline and after flow reduction. Changes of echocardiographic parameters were compared between the successful and failed weaning group.
Results
Sixty-four of the 92 patients were able to be weaned from VA-ECMO successfully. During VA-ECMO flow study, both lateral e\' and tricuspid annular S\' velocity improved significantly in the successful weaning group, while such findings were not observed in the failed weaning group. From univariable analysis, left heart decompression, improvement of lateral e\' velocity, and improvement of tricuspid annular S\' velocity showed significant association with successful VA-ECMO weaning. Predictability of the model with the change of lateral e\' and tricuspid annular S\' according to the reduction of ECMO flow for successful weaning from VA-ECMO is much higher than that of the model with conventional echocardiographic predictors from previous studies (left ventricular ejection fraction > 20%-25%, left ventricular time-velocity integral ≥ 10 cm, mitral annulus S\' ≥ 6 cm/sec).
Conclusions
Improvement of lateral e\' velocity and tricuspid annular S\' velocity during VA-ECMO flow study may better represent cardiac reserve from a recovering heart than conventional echocardiographic parameters at minimal flow. Assessment of tissue Doppler parameters during ECMO flow study is a simple and feasible method to guide physicians on the optimal time to wean from ECMO.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:414-422.e4
Kim D, Jang WJ, Park TK, Cho YH, ... Jeon ES, Yang JH
J Am Soc Echocardiogr: 30 Mar 2021; 34:414-422.e4 | PMID: 33321165
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Abstract

Usefulness of Transesophageal Echocardiography in the Evaluation of Celiac Trunk and Superior Mesenteric Artery Involvement in Acute Aortic Dissection.

Moral S, Avegliano G, Cuéllar H, Ballesteros E, ... Gutiérrez L, Evangelista A
Mesenteric ischemia is a serious complication of acute aortic dissection (AAD), and its early diagnosis is vital for prognosis and appropriate treatment indication. Arteries affected by this complication are the celiac trunk and superior mesenteric artery, and their evaluation is usually based on computed tomographic angiography. Transesophageal echocardiography is also a useful technique for diagnosing AAD and is essential in monitoring surgical or endovascular treatment when computed tomographic angiography is not available. However, the usefulness of transesophageal echocardiography for evaluating celiac trunk and superior mesenteric artery involvement and mesenteric ischemia mechanisms in AAD is not well established. Real-time information on mesenteric malperfusion is needed at the bedside, in primary care facilities, and in the operating room to achieve prompt diagnosis and better therapeutic management. The aims of this review are to assess the role of TEE to diagnose celiac trunk and superior mesenteric artery involvement in AAD, determine the mechanisms that can cause flow obstruction in patients with mesenteric ischemia, and analyze possible implications in the treatment of this complication.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:327-335
Moral S, Avegliano G, Cuéllar H, Ballesteros E, ... Gutiérrez L, Evangelista A
J Am Soc Echocardiogr: 30 Mar 2021; 34:327-335 | PMID: 33385502
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Abstract

Layer-Specific Strain Is Preload Dependent: Comparison between Speckle-Tracking Echocardiography and Cardiac Magnetic Resonance Feature-Tracking.

Grund FF, Kristensen CB, Myhr KA, Vejlstrup N, Hassager C, Mogelvang R
Background
Speckle-tracking echocardiographic (STE) imaging and cardiac magnetic resonance feature-tracking (CMR-FT) are novel imaging techniques enabling layer-specific quantification of myocardial deformation. Conventional echocardiographic parameters are load dependent, but few studies have investigated the effects of loading conditions on STE and CMR-FT layer-specific strain and the interchangeability of the two modalities. The aim of this study was to evaluate the effects of acute preload augmentation by saline infusion on STE and CMR-FT longitudinal and circumferential layer-specific strain parameters and their intermodal agreement.
Methods
A total of 80 subjects, including 41 control subjects (mean age, 40 ± 12 years; 49% men) and 39 patients with cardiac disease (mean age, 47 ± 15 years; 92% men) were examined using STE and CMR-FT layer-specific strain analysis before and after saline infusion (median, 2.0 L) with quantification of transmural global longitudinal strain (GLS), epicardial GLS, endocardial GLS, transmural global circumferential strain (GCS), epicardial GCS, and endocardial GCS in addition to epicardial-endocardial gradients. Bland-Altman plots and Pearson correlation coefficients were used to evaluate agreement between the two modalities across all strain parameters.
Results
Acute saline infusion increased all STE and CMR-FT layer-specific strain parameters in both groups. STE and CMR-FT GLS increased by 1.4 ± 1.5% and 1.5 ± 2.0% (P < .001) in control subjects and by 0.9 ± 1.8% and 0.9 ± 1.9% (P < .001) in patients with cardiac disease. STE and CMR-FT GCS increased by 2.0 ± 2.2% and 1.8 ± 2.3% (P < .001) in control subjects and by 1.8 ± 2.3% and 1.7 ± 3.6% in patients with cardiac disease (P < .001 and P = .03). STE longitudinal strain correlated strongly with corresponding CMR-FT longitudinal strain (GLS, epicardial GLS, and endocardial GLS: r = 0.81, r = 0.82, and r = 0.81, respectively) despite poor intermodal agreement (bias ± limits of agreement, -2.84 ± 4.06%, 0.16 ± 3.68%, and 2.33 ± 3.52%, respectively) whereas GCS, epicardial GCS, and endocardial GCS correlated weakly between the two modalities (r = 0.28, r = 0.19, and r = 0.34, respectively) and displayed poor intermodal agreement (bias ± limits of agreement, -1.33 ± 6.86%, 4.43 ± 6.49%, and -9.92 ± 8.55%, respectively).
Conclusions
STE and CMR-FT longitudinal and circumferential layer-specific strain parameters are preload dependent in both control subjects and patients with cardiac disease. STE and CMR-FT longitudinal layer-specific strain parameters are strongly correlated, whereas circumferential layer-specific strain parameters are weakly correlated. STE and CMR-FT longitudinal and circumferential strain should not be used interchangeably, because of poor intermodal agreement.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Mar 2021; 34:377-387
Grund FF, Kristensen CB, Myhr KA, Vejlstrup N, Hassager C, Mogelvang R
J Am Soc Echocardiogr: 30 Mar 2021; 34:377-387 | PMID: 33421611
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Abstract

Three-Dimensional Echocardiographic Left Atrial Appendage Volumetric Analysis.

Meltzer SN, Phatak PM, Fazlalizadeh H, Chang I, ... Kumar P, Medvedofsky D
Background
Left atrial appendage (LAA) echocardiographic assessment is difficult because of its complex shape and relatively small size. Three-dimensional echocardiographic (3DE) imaging can overcome the limitations of two-dimensional (2D) imaging. Pulsed wave (PW) Doppler is the only currently standard LAA functional parameter. The aim of this study was to test a new approach for 3DE volumetric analysis to obtain LAA ejection fraction (EF), its size and shape.
Methods
Transesophageal 2D and 3D LAA images were prospectively obtained in 159 consecutive patients. LAA volumes were measured from 3DE images using available software. PW Doppler was considered the reference value for LAA function, and used for comparison with LAA EF. Comparison to cardiac computed tomography (CT) was performed in a subgroup of 32 patients. Comparisons included linear regression and Bland-Altman analyses. Repeated measurements were performed to assess measurement variability.
Results
Nine patients were excluded because of suboptimal image quality (94%feasibility). 3D LAA calculated EF was in good agreement with LAA PW measurements. 3D morphologic evaluation showed that 43% of the patients had \"chicken wing\", 33% \"cactus\", 19% \"windsock\" and 5% Cauliflower shape. At the time of data acquisition, patients with atrial fibrillation had non-significantly larger LAA end-systolic and diastolic volumes (ESV, EDV), leading to a lower calculated EF. 3DE LAA ESVs were in good agreement with cardiac CT (r = 0.75), with small biases: -2.5±3.9ml. Reproducibility was better for larger LAA volumes.
Conclusions
A novel 3DE approach can determine geometry, size, and function of the LAA. A new parameter, LAA EF, provides functional quantitation.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 24 Mar 2021; epub ahead of print
Meltzer SN, Phatak PM, Fazlalizadeh H, Chang I, ... Kumar P, Medvedofsky D
J Am Soc Echocardiogr: 24 Mar 2021; epub ahead of print | PMID: 33775733
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Abstract

The Prognostic Value of Right Atrial Strain Imaging in Patients with Pre-Capillary Pulmonary Hypertension.

Hasselberg NE, Kagiyama N, Soyama Y, Sugahara M, ... Simon MA, Gorcsan J
Background
Right ventricular (RV) failure in patients with pulmonary hypertension (PH) is associated with unfavorable clinical events and a poor prognosis. Elevation of right atrial (RA) pressure is established as a marker for RV failure. However, the additive prognostic value of RA mechanical function is unclear.
Materials and methods
We tested the hypothesis that RA function by strain echocardiography has prognostic usefulness by studying 165 consecutive patients with pre-capillary PH defined invasively: mean pulmonary artery pressure ≥ 25mmHg and pulmonary capillary wedge pressure < 15 mmHg. Speckle tracking strain analyses of the RA and RV were performed, along with routine measures. Peak RA strain values from 6 segments using generic speckle-tracking software were averaged to RA peak longitudinal strain, representing RA global reservoir function. The primary endpoint was all-cause mortality during 5 years of follow-up. RA strain was similarly analyzed in a control group of 16 normal subjects for comparison.
Results
There were 151 PH patients (aged 55±16 years, 73% women, World Health Organization functional class 2.6±0.6), after 14 exclusions (3 atrial septal defects and 11 with left ventricular ejection fraction < 50%). RA strain was feasible in 93% and RV strain in 88%. RA peak longitudinal strain was significantly reduced in PH patients compared with controls, as expected (p<0.001). During 5 years follow-up, 73 (48%) patients died. Patients with RA peak strain in the lowest quartile (<25%) had a significant risk of death (p=0.006), even after correcting for confounding variables. RA strain was independently associated with survival in multivariable analysis (p = 0.039) and had additive prognostic value to RV strain (log rank p = 0.002) in subgroup analysis.
Conclusions
RA peak longitudinal strain had additive prognostic usefulness to other clinical measures including RV strain, RA area, and RA pressure in patients with PH. RA mechanical function by strain imaging has potential for clinical applications in PH patients.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Mar 2021; epub ahead of print
Hasselberg NE, Kagiyama N, Soyama Y, Sugahara M, ... Simon MA, Gorcsan J
J Am Soc Echocardiogr: 23 Mar 2021; epub ahead of print | PMID: 33774108
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Abstract

Dynamic Systolic Changes in Tricuspid Regurgitation Vena Contracta Size and Proximal Isovelocity Surface Area in Hypoplastic Left Heart Syndrome: A Three-Dimensional Color Doppler Echocardiography Study.

Li L, Colen TM, Jani V, Barnes BT, ... Danford DA, Kutty S
Purpose
The purpose of our study was to investigate the dynamic changes in the vena contracta (VC) and proximal isovelocity surface area (PISA) through systole in patients with hypoplastic left heart syndrome (HLHS) and tricuspid regurgitation (TR), and to identify the stage of systole (early, mid, or late) where VC and PISA radius are optimal.
Methods
We prospectively studied 28 patients with HLHS using continuous 2D and 3D echocardiography (2DE, 3DE) (X7-2, iE33, Philips). 2D vena contracta width (VCW), 3D vena contracta area (VCA), and PISA radii (2D and 3D) were measured frame-by-frame throughout systole. The maximal 2D VCW, 3D VCA, and PISA radii in the first, middle, and last third of systole were compared, and correlations explored with 3D tricuspid annular areas, right atrial (RA) volumes and right ventricular (RV) volumes.
Results
In all, 35 datasets that met inclusion criteria were analyzed. On frame-by-frame analysis, maximal 2D VCW and 3D VCA were found in the 1st third of systole in 17% and 20% of studies, in the 2nd third in 34% and 31%, and final third in 49% and 49%. Similarly, the maximal 2D and 3D PISA radii were found in the 1st third of systole in 26% and 17% of studies, in the 2nd third in 28% and 34%, and in the final third in 46% and 49%.
Conclusions
In HLHS, detailed temporal analysis of TR associated VC and PISA by 2DE and 3DE reveals no reliable pattern predicting when in systole these parameters peak. Frame by frame measurement is necessary for identification of maximal VC and PISA radius on 2DE and 3DE color Doppler because the severity of TR could be underestimated due to temporal variability in VC and PISA.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Mar 2021; epub ahead of print
Li L, Colen TM, Jani V, Barnes BT, ... Danford DA, Kutty S
J Am Soc Echocardiogr: 18 Mar 2021; epub ahead of print | PMID: 33753189
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Abstract

Influence of Ventricular Wringing on the Preservation of Left Ventricular Ejection Fraction in Cardiac Amyloidosis.

Mora V, Roldán I, Bertolín J, Faga V, ... Arbucci R, Lowenstein J
Background
The purpose of this work was to determine the influence of myocardial wringing on ventricular function in patients with cardiac amyloidosis (CA).
Methods
Fifteen healthy volunteers (group 1) and 34 patients with CA (17 with left ventricular ejection fractions [LVEFs] ≥ 53% [group 2] and 17 with LVEFs < 53% [group 3]) were evaluated using two-dimensional speckle-tracking echocardiography. A control group of mass-matched patients (n = 20) with left ventricular (LV) hypertrophy and LVEFs ≥ 53% was also included. Longitudinal strain (LS), circumferential strain, and LV twist and torsion were calculated. Deformation index (DefI), a new parameter of wringing, calculated as twist/LS, that takes into account actions that occur simultaneously during LV systole (i.e., longitudinal shortening and twist), was evaluated. Torsional and wringing parameters were calculated according to LVEF.
Results
Lower global values of LS and circumferential strain were observed among patients with CA (LS: group 1, -20.6 ± 2.5%; group 2, -11.6 ± 4.1%; group 3, -9.0 ± 3.1%; circumferential strain: group 1, -22.7 ± 4.9%; group 2, -14.4 ± 8.0%; group 3, -13.6 ± 3.8%; P < .001 for both). Torsion did not vary between group 2 and group 1 (2.5 ± 1.1°/cm vs 2.7 ± 0.8°/cm, P = NS). In contrast, DefI was greater in group 2 than in group 1 (-1.8 ± 0.8°/% vs -1.0 ± 0.3°/%, P < .01). Torsion and DefI were lower in group 3 (1.2 ± 0.7°/cm and -1.1 ± 0.6°/%, respectively, P < .001 for both) than in group 2. DefI was similar in patients with LV hypertrophy (-1.7 ± 0.6°/%, P = NS) and group 2.
Conclusions
In patients with CA, preservation of LVEF depends on greater ventricular wringing. DefI, a parameter that integrates the twist and the simultaneous longitudinal shortening of the left ventricle, is a more accurate indicator of the efficacy of this mechanism.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 17 Mar 2021; epub ahead of print
Mora V, Roldán I, Bertolín J, Faga V, ... Arbucci R, Lowenstein J
J Am Soc Echocardiogr: 17 Mar 2021; epub ahead of print | PMID: 33744403
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Abstract

Recurrence of Functional Versus Organic Mitral Regurgitation After Transcatheter Mitral Valve Repair: Implications from Three-Dimensional Echocardiographic Analysis of Mitral Valve Geometry and Left Ventricular Dilation for a Point of No Return.

Buck T, Eiswirth N, Farah A, Kahlert H, ... Kahlert P, Plicht B
Background
MitraClip implantation has become the standard transcatheter mitral valve repair (TMVR) technique for severe mitral regurgitation (MR). However, approximately one third of patients have poor outcomes, with MR recurrence at follow-up. The aim of this study was to investigate whether quantitative analysis of mitral valve (MV) geometry on three-dimensional (3D) echocardiography can identify geometric parameters associated with the recurrence of severe functional MR (FMR) versus organic MR (OMR) at 6-month follow-up after TMVR using the MitraClip.
Methods
Sixty-one patients with severe FMR (n = 45) or OMR (n = 16) who underwent transesophageal 3D echocardiography before and 6 months after TMVR were retrospectively analyzed. MV geometry was quantified using 3D echocardiography software. Vena contracta area (VCA) at 6-month follow-up was used to define two outcome groups: patients with good results with VCA < 0.6 cm2 (MR < 0.6) and those with MR recurrence with VCA ≥ 0.6 cm2 (MR ≥ 0.6).
Results
MR recurrence was found in 34% of all study patients (21 of 61). In patients with FMR, significant differences between MR < 0.6 and MR ≥ 0.6 were found at baseline for tenting index (1.13 vs 1.23, P = .004), tenting volume (2.8 vs 4.0 ml, P = .04), indexed left ventricular (LV) end-diastolic volume (68.0 vs 99.9 ml/m2, P = .001), and VCA (0.71 vs 1.00 cm2, P = .003); no significant parameters of MR recurrence were found in patients with OMR. Multivariate analysis identified indexed LV end-diastolic volume as the strongest independent determinant of MR recurrence. Receiver operating characteristic analysis identified a tenting index of 1.185 (area under the curve 0.79) and indexed LV end-diastolic volume of 88 ml/m2 (area under the curve 0.76) to best discriminate between MR < 0.6 and MR ≥ 0.6.
Conclusions
MR recurrence after TMVR in patients with FMR is associated with advanced LV dilation and MV tenting before TMVR, which provides clinical implications for a point of no return beyond which progressive LV dilation with MV geometry dilation and tethering cannot be effectively prevented by TMVR. In contrast, no significant determinants of MR recurrence and progressive MV annular dilation could be identified in patients with OMR.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 12 Mar 2021; epub ahead of print
Buck T, Eiswirth N, Farah A, Kahlert H, ... Kahlert P, Plicht B
J Am Soc Echocardiogr: 12 Mar 2021; epub ahead of print | PMID: 33722676
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Impact:
Abstract

Novel Echocardiographic Algorithm for Right Ventricular Mass Quantification: Cardiovascular Magnetic Resonance and Clinical Prognosis Validation.

Kochav J, Chen J, Nambiar L, Mitlak HW, ... Weinsaft JW, Kim J
Background
Right ventricular hypertrophy (RVH) provides a key remodeling index alterable by pulmonary hypertension. Although echocardiography commonly integrates linear wall thickness and chamber dimensions to quantify left ventricular remodeling, the utility of an equivalent right ventricular (RV)-based approach is unknown.
Methods
This was a retrospective analysis of 200 patients undergoing transthoracic echocardiography and cardiac magnetic resonance (CMR) within 30 days (median = 3 days; interquartile range, 15 days), stratified by echocardiography-quantified pulmonary artery systolic pressure (<35, 35 to <55, 55 to <75, or ≥75 mm Hg). Echocardiographic assessment included RV linear dimensions in parasternal long-axis and apical four-chamber views and wall thicknesses in parasternal long-axis, four-chamber, and subcostal views. Subcostal wall thickness was integrated with chamber diameters to calculate RV mass, which was tested in relation to CMR-quantified RV mass and all-cause mortality.
Results
Echocardiography-based quantification of all linear dimensions was feasible in 95% of patients (190 of 200). RV wall thicknesses in all orientations increased in relation to pulmonary artery systolic pressure (P < .001) and was greater among patients with, versus those without, CMR-evidenced RVH (P < .001 for all). Correlations between echocardiography and CMR were greatest for RV basal diameter (r = 0.73), RV subcostal wall thickness (r = 0.71), and global RV mass (r = 0.82; P < .001 for all). Echocardiography-derived global RV mass cutoffs were established in a derivation cohort and tested in a validation cohort. Results demonstrated good sensitivity and specificity (75.5% and 74.0%, respectively) in relation to CMR-quantified RVH. During follow-up (median, 4.2 years), 18% of patients (n = 36) died. Echocardiography-evidenced RVH (hazard ratio, 1.98; 95% CI, 1.09-3.88; P = .048) conferred similar mortality risk compared with RVH on CMR (hazard ratio, 2.41; 95% CI, 1.22-4.78; P = .01).
Conclusions
Echocardiography-quantified RV parameters provide a robust index of RV afterload. Global RV mass calculated using a novel echocardiographic formula based on readily available linear indices yields good diagnostic performance for CMR-evidenced RVH and confers increased mortality risk.

Published by Elsevier Inc.

J Am Soc Echocardiogr: 10 Mar 2021; epub ahead of print
Kochav J, Chen J, Nambiar L, Mitlak HW, ... Weinsaft JW, Kim J
J Am Soc Echocardiogr: 10 Mar 2021; epub ahead of print | PMID: 33716162
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Impact:
Abstract

Augmentation of Tissue Perfusion with Contrast Ultrasound: Influence of Three-Dimensional Beam Geometry and Conducted Vasodilation.

Muller MA, Belcik T, Hodovan J, Ozawa K, ... Sheeran PS, Lindner JR
Background
Cavitation of microbubble contrast agents with ultrasound produces shear-mediated vasodilation and an increase in tissue perfusion. We investigated the influence of the size of the cavitation volume by comparing flow augmentation produced by two-dimensional (2D) versus three-dimensional (3D) therapeutic ultrasound. We also hypothesized that cavitation could augment flow beyond the ultrasound field through release of vasodilators that are carried downstream.
Methods
In 11 rhesus macaques, cavitation of intravenously administered lipid-shelled microbubbles was performed in the proximal forearm flexor muscles unilaterally for 10 min. Ultrasound cavitation (1.3 MHz, 1.5 MPa peak negative pressure) was performed with 2D or 3D transmission with beam elevations of 5 and 25 mm, respectively, and pulsing intervals (PIs) sufficient to allow complete postdestruction refill (5 and 12 sec for 2D and 3D, respectively). Contrast ultrasound perfusion imaging was performed before and after cavitation, using multiplane assessment within and beyond the cavitation field in 1.5-cm increments. Cavitation in the hindlimb of mice using 2D ultrasound at a PI of 1 or 5 sec was performed to examine microvascular flow changes from cavitation in only arteries versus the microcirculation.
Results
In primates, the degree of muscle flow augmentation in the center of the cavitation field was similar for 2D and 3D conditions (five- to sixfold increase for both, P < .01 vs baseline). The spatial extent of flow augmentation was only modestly greater for 3D cavitation because of an increase in perfusion with 2D transmission that was detected outside of the cavitation field. In mice, cavitation in the microvascular compartment (PI 5 sec) produced the greatest degree of flow augmentation, yet cavitation in the arterial compartment (PI 1 sec) still produced a three- to fourfold increase in flow (P < .001 vs control). The mechanism for flow augmentation beyond the cavitation zone was investigated by in vitro studies that demonstrated cavitation-related release of vasodilators, including adenosine triphosphate and nitric oxide, from erythrocytes and endothelial cells.
Conclusions
Compared with 2D transmission, 3D cavitation of microbubbles generates a similar degree of muscle flow augmentation, possibly because of a trade-off between volume of cavitation and PI, and only modestly increases the spatial extent of flow augmentation because of the ability of cavitation to produce conducted effects beyond the ultrasound field.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 09 Mar 2021; epub ahead of print
Muller MA, Belcik T, Hodovan J, Ozawa K, ... Sheeran PS, Lindner JR
J Am Soc Echocardiogr: 09 Mar 2021; epub ahead of print | PMID: 33711457
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Impact:
Abstract

Delayed Echo Enhancement Imaging to Quantify Myocardial Infarct Size.

Zeng P, Qian L, Lof J, Stolze E, ... Xie F, Porter TR
Background
Perfluoropropane droplets formulated from commercial microbubbles exhibit different acoustic characteristics than their parent microbubbles, most likely from enhanced endothelial permeability. This enhanced permeability may permit delayed echo-enhancement imaging (DEEI) similar to delayed enhancement magnetic resonance imaging (DE-MRI). We hypothesized this would allow detection and quantification of myocardial scar.
Methods
In 15 pigs undergoing 90 minutes of left anterior descending ischemia by either balloon (n = 13) or thrombotic occlusion (n = 2), DE-MRI was performed at 2-24 days postocclusion. Delayed echo-enhancement imaging was performed at 2-4 minutes following an intravenous injection of 1 mL of 50% Definity (Lantheus Medical) compressed into 180 nm droplets; DEEI was attempted in all pigs with single-pulse harmonic imaging at 1.7 transmit/3.4 MHz receive. Myocardial defects observed with DEEI were quantified (percentage of infarct area) and compared with DE-MRI as well as postmortem staining. In six pigs, multipulse low-mechanical index (MI) fundamental nonlinear imaging (FNLI) with intermittent high-MI impulses was performed to determine whether droplet activation within the infarct zone was achievable with a longer pulse duration.
Results
The range of infarct size area by DE-MRI ranged from 0% to 46% of total left ventricular area. Single-pulse harmonic imaging detected a contrast defect that correlated closely with infarct area by DE-MRI (r = 0.81, P = .0001). The FNLI high-MI impulses resulted in droplet activation in both the infarct and normal zones. Harmonic subtraction of the FNLI images resulted in infarct zone enhancement that also correlated closely with infarct size (r = 0.83; P = .04). Droplets were observed on postmortem transmission electron microscopy within myocytes of the infarct and remote normal zone.
Conclusion
Intravenously Definity nanodroplets can be utilized to detect and quantify infarct zone at the bedside using DEEI techniques.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 08 Mar 2021; epub ahead of print
Zeng P, Qian L, Lof J, Stolze E, ... Xie F, Porter TR
J Am Soc Echocardiogr: 08 Mar 2021; epub ahead of print | PMID: 33711458
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Abstract

Cardiac Resynchronization Therapy Response Assessment with Electromechanical Activation Mapping within 24 Hours of Device Implantation: A Pilot Study.

Melki L, Wang DY, Grubb CS, Weber R, ... Garan H, Konofagou EE
Background
Cardiac resynchronization therapy (CRT) response assessment relies on the QRS complex narrowing criterion. Yet one third of patients do not improve despite narrowed QRS after implantation. Electromechanical wave imaging (EWI) is a quantitative echocardiography-based technique capable of noninvasively mapping cardiac electromechanical activation in three dimensions. The aim of this exploratory study was to investigate the EWI technique, sensitive to ventricular dyssynchrony, for informing CRT response on the day of implantation.
Methods
Forty-four patients with heart failure with left bundle branch block or right ventricular (RV) paced rhythm and decreased left ventricular ejection fraction (LVEF; mean, 25.3 ± 9.6%) underwent EWI without and with CRT within 24 hours of device implantation. Of those, 16 were also scanned while in left ventricular (LV) pacing. Improvement in LVEF at 3-, 6-, or 9-month follow-up defined (1) super-responders (ΔLVEF ≥ 20%), (2) responders (10% ≤ ΔLVEF < 20%), and (3) nonresponders (ΔLVEF ≤ 5%). Three-dimensionally rendered electromechanical maps were obtained under RV, LV, and biventricular CRT pacing conditions. Mean RV free wall and LV lateral wall activation times were computed. The percentage of resynchronized myocardium was measured by quantifying the percentage of the left ventricle activated within 120 msec of QRS onset. Correlations between percentage of resynchronized myocardium and type of CRT response were assessed.
Results
LV lateral wall activation time was significantly different (P ≤ .05) among all three pacing conditions in the 16 patients: LV lateral wall activation time with CRT in biventricular pacing (73.1 ± 17.6 msec) was lower compared with LV pacing (89.5 ± 21.5 msec) and RV pacing (120.3 ± 17.8 msec). Retrospective analysis showed that the percentage of resynchronized myocardium with CRT was a reliable response predictor within 24 hours of implantation for significantly (P ≤ .05) identifying super-responders (n = 7; 97.7 ± 1.9%) from nonresponders (n = 17; 89.9 ± 9.9%).
Conclusion
Electromechanical activation mapping constitutes a valuable three-dimensional visualization tool within 24 hours of implantation and could potentially aid in the timely assessment of CRT response rates, including during implantation for adjustment of lead placement and pacing outcomes.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 03 Mar 2021; epub ahead of print
Melki L, Wang DY, Grubb CS, Weber R, ... Garan H, Konofagou EE
J Am Soc Echocardiogr: 03 Mar 2021; epub ahead of print | PMID: 33675941
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Abstract

Echocardiographic Guidance of Intentional Leaflet Laceration prior to Transcatheter Aortic Valve Replacement: A Structured Approach to the Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction Procedure.

Protsyk V, Meineri M, Kitamura M, Flo Forner A, ... Abdel-Wahab M, Ender JK
Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a recently developed technique to reduce the risk of ostial coronary obstruction during transcatheter aortic valve replacement. Intraprocedural fluoroscopy and transesophageal echocardiography imaging are used complimentarily to guide the procedure. So far, no structured echocardiographic imaging protocol has been described for this intervention. Based on an experience of more than 50 BASILICA procedures at two different institutions, we present a step-by-step approach for transesophageal echocardiography guidance during BASILICA and highlight anatomical and procedural characteristics from an echocardiographic perspective.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 02 Mar 2021; epub ahead of print
Protsyk V, Meineri M, Kitamura M, Flo Forner A, ... Abdel-Wahab M, Ender JK
J Am Soc Echocardiogr: 02 Mar 2021; epub ahead of print | PMID: 33675944
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Impact:
Abstract

Simple Two-Dimensional Echocardiographic Scoring System for the Estimation of Left Ventricular Filling Pressure.

Murayama M, Iwano H, Nishino H, Tsujinaga S, ... Nagai T, Anzai T
Background
When left ventricular filling pressure (LVFP) increases, the mitral valve opens early and precedes tricuspid valve opening in early diastole. The authors hypothesized that a visually assessed time sequence of atrioventricular valve opening could become a new marker of elevated LVFP. The aim of this study was to test the diagnostic ability of a novel echocardiographic scoring system, the visually assessed time difference between mitral valve and tricuspid valve opening (VMT) score, in patients with heart failure.
Methods
One hundred nineteen consecutive patients who underwent cardiac catheterization within 24 hours of echocardiographic examination were retrospectively analyzed as a derivation cohort. In addition, a prospective study was conducted to validate the diagnostic ability of the VMT score in 50 patients. Elevated LVFP was defined as mean pulmonary artery wedge pressure (PAWP) ≥ 15 mm Hg. The time sequence of atrioventricular valve opening was visually assessed and scored (0 = tricuspid valve first, 1 = simultaneous, 2 = mitral valve first). When the inferior vena cava was dilated, 1 point was added, and VMT score was ultimately graded as 0 to 3. Cardiac events were recorded for 1 year after echocardiography.
Results
In the derivation cohort, PAWP was elevated with higher VMT scores (score 0, 10 ± 5; score 1, 12 ± 4; score 2, 22 ± 8; score 3, 28 ± 4 mm Hg; P < .001, analysis of variance). VMT score ≥ 2 predicted elevated PAWP with accuracy of 86% and showed incremental predictive value over clinical variables and guideline-recommended diastolic function grading. These observations were confirmed in the prospective validation cohort. Importantly, VMT score ≥ 2 discriminated elevated PAWP with accuracy of 82% in 33 patients with monophasic left ventricular inflow in the derivation cohort. Kaplan-Meier analysis demonstrated that patients with VMT scores ≥ 2 were at higher risk for cardiac events than those with VMT scores ≤ 1 (P < .001).
Conclusions
VMT scoring could be a novel additive marker of elevated LVFP and might also be associated with adverse outcomes in patients with heart failure.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 02 Mar 2021; epub ahead of print
Murayama M, Iwano H, Nishino H, Tsujinaga S, ... Nagai T, Anzai T
J Am Soc Echocardiogr: 02 Mar 2021; epub ahead of print | PMID: 33675942
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Abstract

Impact of a Mandated Accreditation Process on 1,045 Registered Echocardiographic Service Providers in a Previously Unregulated, Publicly Funded Environment.

Sanfilippo AJ, Kolos A, Chan K, Leong-Poi H, ... Woodward G, Yared K
Background
This review was undertaken to examine the impact of a standards-based, mandated accreditation process on several aspects of echocardiographic service delivery in a single-payer, previously unregulated environment.
Methods
In the province of Ontario, virtually all echocardiographic services are funded by the Ministry of Health and Long Term Care. The Echocardiography Quality Improvement (EQI) process was introduced in 2012 and subsequently linked formally to reimbursement in 2016. Previously, payment for echocardiographic services in Ontario was unregulated. The impact of EQI on the number of facilities, echocardiographic volumes, costs, quality standards, and physician service provision were compared before and after implementation.
Results
Of the initial 1,045 registrants, 604 (57.8%) have been accredited or accreditation is expected having successfully resolved identified deficiencies. The remaining registrants were either never functionally operating (323 [30.9%]) or have withdrawn services (118 [11.3%]) since mandatory registration became a requirement for reimbursement. A number of factors identified facilities that were able to most promptly meet EQI standards, including hospital-based, academic, and multiple-physician facilities. The average annual increase in the utilization of echocardiographic services before EQI was 6.7%, decreasing to 2.7% since. The proportion of repeat examinations decreased in community-based facilities. Since 2013, costs for echocardiographic services have totaled about $92.3 million less than predicted by pre-2012 trends. To address standards, some small, more isolated facilities sought out alliances with larger facilities, particularly those affiliated with academic hospitals.
Conclusions
EQI is demonstrably a means for improving quality while reducing the rate of growth and repeat examinations.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:308-315
Sanfilippo AJ, Kolos A, Chan K, Leong-Poi H, ... Woodward G, Yared K
J Am Soc Echocardiogr: 27 Feb 2021; 34:308-315 | PMID: 33191003
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Impact:
Abstract

Sources of Variability in Vena Contracta Area Measurement for Tricuspid Regurgitation Severity Grading: Comparison of Technical Settings and Vendors.

Liu Y, Chen B, Zhang Y, Zuo W, ... Shu X, Ge J
Background
Previous studies found different cutoffs of vena contracta area (VCA) to define severe tricuspid regurgitation (TR). The aim of this study was to investigate the factors associated with such variability by comparing technical variables and vendors.
Methods
Sixty-nine patients with scheduled tricuspid surgery were included in this prospective study. For each patient, TR data sets were obtained on three-dimensional color Doppler transthoracic echocardiography on at least two of three systems: GE Vivid E95 (n = 39), Siemens SC2000 Prime (n = 64), and Philips EPIQ 7C (n = 60). VCA was measured using default settings or with color baseline shifted on all three platforms and with minimal color gain (10%-20%) on the GE platform.
Results
Color gain reduction and baseline shift caused significant change sin VCA measurement (-46% and 10%, respectively). Intervendor comparison exhibited wide limits of agreement (narrowest range, -74% to 167%), with either default or optimized settings. Different technical settings, platforms, and reference methods all produced different VCA cutoffs for severe TR.
Conclusions
VCA measurement in TR is sensitive to technical factors and demonstrates intervendor variability. Technical variables in VCA measurement should be reported in detail to allow comparison among research studies. The same vendor and settings should be used for longitudinal analysis of TR VCA in the same patient in multivendor echocardiography laboratories.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:270-278.e1
Liu Y, Chen B, Zhang Y, Zuo W, ... Shu X, Ge J
J Am Soc Echocardiogr: 27 Feb 2021; 34:270-278.e1 | PMID: 33166630
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Abstract

Prognostic Risk Stratification of Patients with Moderate Aortic Stenosis.

Ito S, Miranda WR, Nkomo VT, Boler AN, ... Nishimura RA, Oh JK
Background
Currently risk stratification of moderate aortic stenosis (AS) is still incipient. The aim of this study was to identify prognostic factors in patients with moderate AS.
Methods
The prognosis of patients with moderate AS (1 < aortic valve area ≤ 1.5 cm2) stratified by left ventricular ejection fraction (LVEF; 50%), stroke volume index (SVI; 35 mL/m2), and elevated E/e\' ratio (average, 14) was compared with that of the age- and sex-matched general population.
Results
Of 696 patients (median age, 77 years; aortic valve area 1.3 cm2; 57% men), 279 (40%) died during a median follow-up period of 3.4 years. Mortality was higher in patients with moderate AS than reference (mortality ratio, 2.43; 95% CI, 2.17-2.72). LVEF < 50%, SVI < 35 mL/m2, and elevated E/e\' ratio were present in 113 (17%), 54 (8%), and 330 (54%) patients; mortality ratios were 3.89 (95% CI, 3.07-4.85), 6.40 (95% CI, 4.57-8.71), and 2.58 (95% CI, 2.21-3.00), respectively. Even if LVEF or SVI was preserved, the mortality ratio was more than twice than reference (P < .001), but elevated E/e\' ratio could discriminate additional patients at higher risk (hazard ratio [HR], 2.71; 95% CI, 1.88-3.91). Two hundred one patients (29%) underwent aortic valve replacement at a median of 2.3 years after the diagnosis of moderate AS. LVEF < 50% (HR, 2.98; 95% CI, 1.39-6.56), SVI < 35 mL/m2 (HR, 3.34; 95% CI, 1.02-10.90) and elevated E/e\' ratio (HR, 2.73; 95% CI, 1.26-5.94) were all associated with worse prognosis even if aortic valve replacement was performed.
Conclusions
In patients with moderate AS, those with decreased LVEF and/or SVI are at high risk. Even if these parameters are preserved, patients with elevated E/e\' ratios are at intermediate risk. Further investigation is warranted to assess whether earlier intervention could improve outcomes and reduced cardiac-related death among patients at high and intermediate risk.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:248-256
Ito S, Miranda WR, Nkomo VT, Boler AN, ... Nishimura RA, Oh JK
J Am Soc Echocardiogr: 27 Feb 2021; 34:248-256 | PMID: 33161066
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Abstract

Left Ventricular Myocardial Work in Patients with Severe Aortic Stenosis.

Fortuni F, Butcher SC, van der Kley F, Lustosa RP, ... Delgado V, Ajmone Marsan N
Background
Left ventricular myocardial work (LVMW) is a novel method to assess left ventricular (LV) function using pressure-strain loops that takes into consideration LV afterload. The estimation of LV afterload in patients with severe aortic stenosis (AS) may be challenging, and no study so far has investigated LVMW in this setting. The aim of this study was to develop a method to calculate LVMW in patients with severe AS and to analyze its relationship with heart failure symptoms.
Methods
Indices of LVMW were calculated in 120 patients with severe AS who underwent transcatheter aortic valve replacement and invasive LV and aortic pressure measurements. LV systolic pressure was also derived by adding the mean aortic valve gradient to the aortic systolic pressure. LV global longitudinal strain and echocardiography-derived LV systolic pressure were then incorporated to construct pressure-strain loops of the left ventricle.
Results
An excellent correlation was observed between LVMW indices calculated using the invasive and echocardiography-derived LV systolic pressure. Patients in New York Heart Association functional class III or IV (n = 97 [73%]) had lower LV global longitudinal strain, LV global work index, LV global constructive work, and right ventricular free wall strain compared with those in New York Heart Association functional class I or II. In contrast to LV global longitudinal strain, LV global work index (odds ratio per 100 mm Hg% increase, 0.91; 95% CI, 0.85-0.98; P = .012) and LV global constructive work showed independent associations with New York Heart Association functional class III or IV heart failure symptoms.
Conclusions
The calculation of echocardiography-based LVMW indices is feasible in patients with severe AS. In particular, LV global work index and global constructive work showed independent associations with heart failure symptoms and may provide additional information on myocardial remodeling and function in patients with severe AS.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:257-266
Fortuni F, Butcher SC, van der Kley F, Lustosa RP, ... Delgado V, Ajmone Marsan N
J Am Soc Echocardiogr: 27 Feb 2021; 34:257-266 | PMID: 33181281
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Impact:
Abstract

Normal Values of Right Atrial Size and Function According to Age, Sex, and Ethnicity: Results of the World Alliance Societies of Echocardiography Study.

Soulat-Dufour L, Addetia K, Miyoshi T, Citro R, ... Lang RM, WASE Investigators
Background
The World Alliance Societies of Echocardiography study is a multicenter, international, prospective, cross-sectional study whose aims were to evaluate healthy adult individuals to establish age- and sex-normative values of echocardiographic parameters and to determine whether differences exist among people from different countries and of different ethnicities. The present report focuses on two-dimensional (2D) and three-dimensional (3D) right atrial (RA) size and function.
Methods
Transthoracic 2D and 3D echocardiographic images were obtained in 2,008 healthy adult individuals evenly distributed among subgroups according to sex (1,033 men, 975 women) and age 18 to 40 years (n = 854), 41 to 65 years (n = 653), and >65 years (n = 501). For ethnicity, 34.9% were white, 41.6% Asian, and 9.7% black. Images were analyzed in a core laboratory according to current American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. RA measurements included 2D dimensions, 2D and 3D RA volumes (RAVs) indexed to body surface area (BSA), emptying fraction (EmF), and global longitudinal strain, including total/reservoir, passive/conduit, and active/contractile phases. Differences among age and sex categories and among countries were also examined.
Results
RAVs were larger in men (even after BSA indexing), while 3D total EmF and global longitudinal strain magnitudes were higher in women. For both sexes, there were no significant age-related differences in 2D RAV measurements, but 3D RAV values differed minimally with age, remaining significant after BSA indexing. RA total EmF and reservoir strain and passive EmF and conduit strain magnitude were lower in older groups for both sexes. Interestingly, whereas RA active EmF increased with age, contractile strain magnitude decreased. Considerable geographic variations were identified: Asians of both sexes had significantly lower BSA than non-Asians, and their 2D and 3D end-systolic RAVs were significantly smaller even after BSA indexing. Of note, 2D end-systolic RAVs in this group were considerably lower than normal values provided in the current guidelines.
Conclusions
There is significant sex, age, and geographic variability in normal RA size and function parameters. Current guideline-recommended normal ranges for RA size and function parameters should be adjusted geographically on the basis of the results of this study.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:286-300
Soulat-Dufour L, Addetia K, Miyoshi T, Citro R, ... Lang RM, WASE Investigators
J Am Soc Echocardiogr: 27 Feb 2021; 34:286-300 | PMID: 33212183
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Abstract

Prevalence and Clinical Correlates of Aortic Dilation in Hypertrophic Cardiomyopathy.

Geske JB, Nordhues BD, Orme NM, Tajik AJ, Spittell PC, Ommen SR
Background
Aortic dilation has been associated with various cardiac conditions, although its prevalence and clinical correlates in hypertrophic cardiomyopathy (HCM) remain unclear.
Objectives
The purposes of this study were to define the prevalence of ascending aortic dilation in a large referral population of patients with HCM and to determine clinical and echocardiographic correlates of aortic dilation.
Methods
A total of 1,698 patients with HCM underwent echocardiographic measurement of the tubular ascending aorta (proximal and midlevel) during index evaluation at a tertiary HCM referral center. End-diastolic ascending aorta dimension was indexed to body surface area, with dilation defined for the tubular ascending aorta as 2 SD above the mean (>19 mm/m2) and independently as greater than published age-, sex-, and body surface area- adjusted norms (for the sinus of Valsalva and midlevel). Aortic size and presence of aortic enlargement were correlated with clinical and echocardiographic parameters.
Results
Tubular ascending aortic dilation >19 mm/m2 was present in 303 patients with HCM (18%), and dilation above adjusted norms was present in 210 patients with HCM (13%). The median indexed tubular ascending thoracic aortic dimension was 16.5 (interquartile range, 14.8-18.2) mm/m2. Indexed dimension increased linearly with age (R = 0.53, P < .0001). Women and patients with a history of systemic hypertension were more likely to have tubular aortic enlargement >19 mm/m2 (29.8% vs 9.9% and 24.1% vs 10.5%, respectively, P < .0001 for both). Patients with obstructive physiology were more likely to have tubular aortic enlargement >19 mm/m2 than those without resting or provocable obstruction (19.6% vs 14.4%, P = .007). Using adjusted norms, aortic enlargement was more frequent at the midlevel compared with the sinus of Valsalva (71% vs 29%), more common in patients with hypertension (15.4% vs 10.6%, P = .009), and more common in patients with paroxysmal atrial fibrillation (16.3% vs 11.5%, P = .036), but no other relationships remained statistically significant.
Conclusions
In this large cohort of patients with HCM, aortic dilation was common. The key correlate of tubular aortic enlargement >19 mm/m2, and aortic enlargement greater than adjusted norms included a history of systemic hypertension. Given an increased prevalence of aortic dilation in HCM, further study is needed on the clinical impact of aortic dilation.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:279-285
Geske JB, Nordhues BD, Orme NM, Tajik AJ, Spittell PC, Ommen SR
J Am Soc Echocardiogr: 27 Feb 2021; 34:279-285 | PMID: 33212182
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Impact:
Abstract

Anatomic Concordance of Neonatologist-Performed Echocardiography as Part of Hemodynamics Consultation and Pediatric Cardiology.

Bischoff AR, Giesinger RE, Rios DR, Mertens L, Ashwath R, McNamara PJ
Background
Targeted neonatal echocardiography (TnECHO) performed by neonatologists as part of a hemodynamics consultation is increasingly being used in neonatal intensive care units. To minimize delays in obtaining physiologic data, first echocardiograms may be obtained by the neonatal hemodynamics team and reviewed afterward by a pediatric cardiologist. This practice has not been systematically evaluated. The aim of this study was to compare concordance between anatomic findings on TnECHO and pediatric cardiology reports.
Methods
This was a retrospective evaluation of 339 infants at low risk for congenital heart disease (CHD) admitted to two large referral centers with established neonatal hemodynamics programs who underwent comprehensive TnECHO as their first postnatal echocardiographic examinations. The protocol included comprehensive imaging of intracardiac anatomy, outflow tract concordance and integrity, aortic arch anatomy, pulmonary vein location and flow, and transitional shunts. The hemodynamics consultation note was compared with the cardiology report to determine anatomic concordance or major or minor discrepancies in all first studies.
Results
Anatomic concordance occurred in 97.9% (κ = 0.862; 95% CI, 0.762-0.962; P < .001). There were seven minor discrepancies (small muscular ventricular septal defects and coronary fistulas). The index population included 23 infants (6.7%) with CHD, of whom only one (0.3%) had a ductal-dependent lesion (coarctation of the aorta) which was correctly identified by both teams.
Conclusions
The rate of major CHD in patients considered eligible for hemodynamics consultation was low, and there was high diagnostic concordance between trained neonatal hemodynamics specialists and pediatric cardiology. First echocardiograms obtained by subspecialty neonatologists may provide imaging of sufficient quality to evaluate a critically unwell neonate with low suspicion for critical CHD lesions. These results should not be extrapolated to infants in whom CHD is suspected. This study highlights the importance of formalized, rigorous, and standardized training for neonatologists with hemodynamics expertise who perform timely assessments using TnECHO.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:301-307
Bischoff AR, Giesinger RE, Rios DR, Mertens L, Ashwath R, McNamara PJ
J Am Soc Echocardiogr: 27 Feb 2021; 34:301-307 | PMID: 33220434
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Impact:
Abstract

Excess Mortality Associated with Progression Rate in Asymptomatic Aortic Valve Stenosis.

Benfari G, Nistri S, Marin F, Cerrito LF, ... Rossi A, Ribichini FL
Background
Aortic valve stenosis (AS) is a progressive condition characterized by gradual calcification of the aortic cusps. Progression rate evaluated using echocardiography has been associated with survival. However, data from routine practice covering the whole spectrum of AS severity and the rate of symptom onset are sparse. The aim of this study was to assess outcomes under medical management related to disease progression in asymptomatic patients with a wide range of AS severity.
Methods
Two hundred twenty-nine consecutive asymptomatic patients (mean age, 77 ± 10 years; 55% men) with AS, preserved left ventricular ejection fraction, and two or more echocardiographic examinations performed from 2004 to 2014 were retrospectively included. The median time between the two echocardiographic examinations was 24 months (interquartile range, 15-46 months). Patients were identified as rapid progressors if the annualized difference in peak aortic velocity between two echocardiographic examinations was ≥0.3 m/sec/y; others were labeled as slow progressors. The primary end point was mortality during medical follow-up (censoring on aortic valve interventions). The secondary end point was overall mortality.
Results
Rapid progressors accounted for 67 of the 229 patients (29%), and this feature was not associated with baseline characteristics. During a median of 5.8 years (interquartile range, 3.4-8.3 years) of follow-up from the first echocardiographic examination, 102 patients (45%) died, 86 (84%) during medical follow-up. Rapid progression rate predicted excess mortality (vs slow progression rate) after adjustment for age, sex, symptoms, baseline left ventricular ejection fraction, and baseline aortic valve area (hazard ratio, 2.50; 95% CI, 1.48-4.21; P = .0006) and after adjusting for peak aortic velocity and left ventricular ejection fraction obtained at the last echocardiographic examination (hazard ratio, 2.07; 95% CI, 1.25-3.46; P = .005). Among patients with baseline peak aortic velocity < 4 m/sec (nonsevere AS), rapid progression rate was associated with higher 5-year mortality compared with slow progression (57% vs 22% [P < .0001] under medical management and 44% vs 18% [P = .005] overall). Outcomes were comparable between nonsevere AS rapid progressors and baseline severe AS. Progression rate showed incremental prognostic value on receiver operating characteristic curve analysis versus AS severity. Of note, among slow progressors, 11 patients (5%) presented with high rates of symptom development and poor outcomes related to ventricular dysfunction or other advanced AS features.
Conclusions
Progression rate is an individual, almost unpredictable feature among patients with AS. Rapid progression is an incremental marker of excess mortality in asymptomatic patients with AS, independent of clinical and hemodynamic characteristics. Rapid progression rate may identify patients with nonsevere AS at higher risk for events.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:237-244
Benfari G, Nistri S, Marin F, Cerrito LF, ... Rossi A, Ribichini FL
J Am Soc Echocardiogr: 27 Feb 2021; 34:237-244 | PMID: 33253813
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Impact:
Abstract

Spectral Doppler Interrogation of the Pulmonary Veins for the Diagnosis of Cardiac Disorders: A Comprehensive Review.

Fadel BM, Pibarot P, Kazzi BE, Al-Admawi M, ... Echahidi N, Mohty D
Data obtained from echocardiographic studies are used on a daily basis to guide clinical decision-making regarding patient management and the need for additional diagnostic investigations. Interrogation of blood flow in the pulmonary veins by spectral, most often pulsed-wave, Doppler is an important component of any comprehensive echocardiographic study. Whereas it is most often used to help assess left-sided filling pressure and quantify the severity of mitral regurgitation, the pulmonary vein Doppler profile provides added diagnostic insights into several disorders that affect heart function and allows assessment of their hemodynamic consequences on the heart. The aim of this review is to summarize current knowledge in the field of PV Doppler interrogation, highlight the physiological and pathological parameters that influence it, and delineate the manifestations of various cardiovascular disorders on the flow profile.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Feb 2021; 34:223-236
Fadel BM, Pibarot P, Kazzi BE, Al-Admawi M, ... Echahidi N, Mohty D
J Am Soc Echocardiogr: 27 Feb 2021; 34:223-236 | PMID: 33678222
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Impact:
Abstract

Natural History of Moderate Aortic Stenosis with Preserved and Low Ejection Fraction.

Mann TD, Loewenstein I, Ben Assa E, Topilsky Y
Background
There is a shortage of data concerning the natural history of patients with moderate aortic stenosis (AS). The aim of this study was to assess the effect of moderate AS on mortality in the general population and in the subgroups of patients with moderate AS and reduced ejection fractions (EF) and patients with moderate AS and low aortic valve gradients. The study was not designed to address the applicability of treatment in this population.
Methods
Outcomes were compared between patients with moderate AS and a propensity-matched cohort (1:3 ratio) without AS. The primary outcome was survival until end of follow-up.
Results
Among approximately 40,000 patients who underwent echocardiographic evaluations between 2011 and 2016, 952 had moderate AS. Median follow-up duration was 181 weeks (interquartile range, 179-182 weeks) for the entire cohort and 174 weeks (interquartile range, 169-179 weeks) for the propensity-matched groups. Propensity matching successfully balanced most preexisting clinical differences. Increased mortality was observed in the group of patients with moderate AS before propensity matching and persisted following propensity matching (median survival 4.1 vs 5.2 years, P = .008). Survival rates and corresponding standard errors at 1, 2, 3, and 5 years were 80 ± 1% versus 82 ± 0.7%, 70 ± 1.5% versus 74 ± 0.8%, 62 ± 1.7% versus 66 ± 0.9%, and 47 ± 2.4% versus 52 ± 1.3%, respectively. A survival difference was similarly observed for the subgroup analyses of moderate AS and reduced ejection fraction (P = .028) and moderate AS and low aortic valve gradients (P = .039).
Conclusions
Moderate AS is associated with increased mortality. The increased mortality was also observed in the subgroups of patients with either reduced ejection fraction or low aortic valve gradients.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 26 Feb 2021; epub ahead of print
Mann TD, Loewenstein I, Ben Assa E, Topilsky Y
J Am Soc Echocardiogr: 26 Feb 2021; epub ahead of print | PMID: 33652083
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Abstract

Advances in Rheumatic Mitral Stenosis: Echocardiographic, Pathophysiologic, and Hemodynamic Considerations.

Silbiger JJ
Echocardiography is the primary imaging modality used in patients with mitral stenosis. Doppler-derived measurements of mitral pressure half-time are commonly used to calculate mitral valve area, but a number of hemodynamic confounders associated with advanced age limit its utility. Planimetry remains the gold standard for determining mitral valve area and may be performed using two- or three-dimensional imaging. Although the Wilkins score has been used for >30 years to predict balloon mitral valvuloplasty outcomes, newer scoring systems have been proposed to improve predictive accuracy. Some patients undergoing technically successful balloon mitral valvuloplasty may not have satisfactory clinical outcomes. These individuals may be identified by the presence of reduced net atrioventricular compliance, which can be measured echocardiographically. Exercise testing may be useful in patients with mitral stenosis whose symptomatic status is incongruous their mitral valve area. Last, reduced left atrial systolic strain, an indicator of poor left atrial compliance, has been shown to reliably predict adverse outcomes in patients with mitral stenosis. The author discusses the hemodynamics and path ophysiology of mitral stenosis and reviews current and emerging roles of echocardiography in its evaluation.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 26 Feb 2021; epub ahead of print
Silbiger JJ
J Am Soc Echocardiogr: 26 Feb 2021; epub ahead of print | PMID: 33652082
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Abstract

Venous Flow Variation Predicts Preoperative Pulmonary Venous Obstruction in Children with Total Anomalous Pulmonary Venous Connection.

White BR, Faerber JA, Katcoff H, Glatz AC, Mascio CE, Cohen MS
Background
Identifying preoperative pulmonary venous obstruction in total anomalous pulmonary venous connection is important to guide treatment planning and risk prognostication. No standardized echocardiographic definition of obstruction exists in the literature. Definitions based on absolute velocities are affected by technical limitations and variations in pulmonary venous return. The authors developed a metric to quantify pulmonary venous blood flow variation: pulmonary venous variability index (PVVI). The aim of this study was to demonstrate its accuracy in defining obstruction.
Methods
All patients with total anomalous pulmonary venous connection at a single institution were identified. Echocardiograms were reviewed, and maximum (Vmax), mean (Vmean), and minimum (Vmin) velocities along the pulmonary venous pathway were measured. PVVI was defined as (Vmax - Vmin)/Vmean. These metrics were compared with pressures measured on cardiac catheterization. Echocardiographic measures were then compared between patients with and without clinical preoperative obstruction (defined as a need for preoperative intubation, catheter-based intervention, or surgery within 1 day of diagnosis), as well as pulmonary edema by chest radiography and markers of lactic acidosis. One hundred thirty-seven patients were included, with 22 having catheterization pressure recordings.
Results
Vmax and Vmean were not different between patients with catheter gradients ≥ 4 and < 4 mm Hg, while PVVI was significantly lower and Vmin higher in those with gradients ≥ 4 mm Hg. The composite outcome of preoperative obstruction occurred in 51 patients (37%). Absolute velocities were not different between patients with and without clinical obstruction, while PVVI was significantly lower in patients with obstruction. All metrics except Vmax were associated with pulmonary edema; none were associated with blood gas metrics.
Conclusions
The authors developed a novel quantitative metric of pulmonary venous flow, which was superior to traditional echocardiographic metrics. Decreased PVVI was highly associated with elevated gradients measured by catheterization and clinical preoperative obstruction. These results should aid risk assessment and diagnosis preoperatively in patients with total anomalous pulmonary venous connection.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 15 Feb 2021; epub ahead of print
White BR, Faerber JA, Katcoff H, Glatz AC, Mascio CE, Cohen MS
J Am Soc Echocardiogr: 15 Feb 2021; epub ahead of print | PMID: 33600926
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Abstract

The Predictive Role of Combined Cardiac and Lung Ultrasound in Coronavirus Disease 2019.

Szekely Y, Lichter Y, Hochstadt A, Taieb P, ... Banai S, Topilsky Y
Background
The aim of this study was to evaluate sonographic features that may aid in risk stratification and to propose a focused cardiac and lung ultrasound (LUS) algorithm in patients with coronavirus disease 2019.
Methods
Two hundred consecutive hospitalized patients with coronavirus disease 2019 underwent comprehensive clinical and echocardiographic examination, as well as LUS, irrespective of clinical indication, within 24 hours of admission as part of a prospective predefined protocol. Assessment included calculation of the modified early warning score (MEWS), left ventricular systolic and diastolic function, hemodynamic and right ventricular assessment, and a calculated LUS score. Outcome analysis was performed to identify echocardiographic and LUS predictors of mortality or the composite event of mortality or need for invasive mechanical ventilation and to assess their adjunctive value on top of clinical parameters and MEWS.
Results
A simplified echocardiographic risk score composed of left ventricular ejection fraction < 50% combined with tricuspid annular plane systolic excursion < 18 mm was associated with mortality (P = .0002) and with the composite event (P = .0001). Stepwise analyses evaluating echocardiographic and LUS parameters on top of existing clinical risk scores showed that addition of tricuspid annular plane systolic excursion and stroke volume index improved prediction of mortality when added to clinical variables but not when added to MEWS. Once echocardiography was added, and patients were recategorized as high risk only if having both high-risk MEWS and high-risk cardiac features, specificity increased from 63% to 87%, positive predictive value from 28% to 48%, and accuracy from 66% to 85%. Although LUS was not associated with incremental risk prediction for mortality above clinical and echocardiographic criteria, it improved prediction of need for invasive mechanical ventilation.
Conclusions
In hospitalized patients with coronavirus disease 2019, a very limited echocardiographic examination is sufficient for outcome prediction. The addition of echocardiography in patients with high-risk MEWS decreases the rate of falsely identifying patients as high risk to die and may improve resource allocation in case of high patient load.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 08 Feb 2021; epub ahead of print
Szekely Y, Lichter Y, Hochstadt A, Taieb P, ... Banai S, Topilsky Y
J Am Soc Echocardiogr: 08 Feb 2021; epub ahead of print | PMID: 33571647
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Abstract

Intervendor Agreement for Right Ventricular Global Longitudinal Strain in Children.

Aly D, Ramlogan S, France R, Schmidt S, ... Goudar SP, Forsha D
Background
Right ventricular global longitudinal strain (RVGLS) has emerged as an important technique for clinical evaluation of (RV) function. The routine application of RVGLS in pediatrics remains limited by a lack of data on agreement between vendors. The aim of this study was to investigate intervendor agreement for RVGLS between the two commonly used analysis vendors in pediatrics, hypothesizing that RVGLS has good intervendor agreement, although it is likely lower than intravendor agreement (inter- and intraobserver reproducibility).
Methods
Seventy infants and children with normal cardiac anatomy and varying ventricular function were included after prospectively obtaining RV-focused four-chamber apical images on the GE Vivid E95. Images were analyzed for RVGLS at acquired frame rates in EchoPAC (GE) and TomTec (TT) and in the compressed Digital Imaging and Communications in Medicine format in TT. Intraclass correlation coefficients and Bland-Altman plots were used to test intervendor agreement and intravendor reproducibility.
Results
RVGLS measurements were equally feasible using TT and EchoPAC analysis (92%). There was good to excellent agreement for RVGLS between TT and EchoPAC analysis, with a relatively higher intraclass correlation coefficient between GE and TT at the acquired frame rate (0.85) than between GE and TT at the compressed frame rate (0.75) and significantly higher agreement in patients with abnormal RV function (0.7-0.9) than those with normal function (0.4-0.6). Intra- andinterobserver reproducibility for RVGLS was excellent (intraclass correlation coefficient = 0.74-0.96). Heart rate ≥ 100 beats/min and acquisition frame rate/heart rate ≤ 0.7 were associated with diminished agreement, especially when compressed data were involved.
Conclusions
RVGLS analyzed using EchoPAC and TT show good agreement, especially when analyzed at acquisition frame rates and in the setting of abnormal RV function. Otherwise, RVGLS should ideally be analyzed using the same vendor, and intervendor comparisons should be undertaken with caution, particularly if data are in a compressed format.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 05 Feb 2021; epub ahead of print
Aly D, Ramlogan S, France R, Schmidt S, ... Goudar SP, Forsha D
J Am Soc Echocardiogr: 05 Feb 2021; epub ahead of print | PMID: 33561494
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Abstract

Prognostic Value of Early Systolic Lengthening by Strain Imaging in Type 2 Diabetes.

Brainin P, Biering-Sørensen T, Jensen MT, Møgelvang R, ... Rossing P, Jørgensen PG
Background
Patients with type 2 diabetes (T2D) have increased risk for subclinical myocardial disease. Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, is a sensitive marker of myocardial dysfunction. The aims of this study were to investigate the prognostic value of ESL in patients with T2D and to determine if global longitudinal strain (GLS) modifies this relationship.
Methods
In this prospective study, speckle-tracking echocardiography was conducted in 703 patients with T2D (62% men; mean age, 63 ± 10 years; median diabetes duration, 11 years; interquartile range, 6-17 years). Patients had no histories of significant heart disease. ESL index was assessed as [-100 × (peak positive systolic strain/maximal strain)] and ESL duration as time from QRS complex on the electrocardiogram to time of peak positive systolic strain. P values ≤ .004 were considered to indicate statistical significance.
Results
During a median follow-up time of 4.8 years (interquartile range, 4.1-5.3 years), 86 patients (12%) experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction, and cardiovascular death. In multivariate models, only the ESL index (hazard ratio [HR], 1.06 per 1% increase; 95% CI, 1.01-1.010; P = .004) but not ESL duration (HR, 1.02 per 1-ms increase; 95% CI, 1.00-1.03; P = .036) were associated with MACE. GLS modified this relationship (P for interaction < .05) such that in patients with low GLS (>-18%), ESL index (HR, 1.06 per 1% increase; 95% CI, 1.02-1.10; P = .003) was associated with MACE, but ESL duration was not (HR, 1.02 per 1-ms increase; 95% CI, 1.00-1.04; P = .005). No associations were found for high GLS (<-18%).
Conclusions
In patients with T2D and no histories of heart disease, ESL provides prognostic information on MACE and may potentially aid in cardiovascular risk stratification.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:127-135
Brainin P, Biering-Sørensen T, Jensen MT, Møgelvang R, ... Rossing P, Jørgensen PG
J Am Soc Echocardiogr: 30 Jan 2021; 34:127-135 | PMID: 33132020
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Abstract

Left Atrial Mechanics Assessed Early during Hospitalization for Cryptogenic Stroke Are Associated with Occult Atrial Fibrillation: A Speckle-Tracking Strain Echocardiography Study.

Deferm S, Bertrand PB, Churchill TW, Sharma R, ... Schwamm LH, Yoerger Sanborn DM
Background
Occult atrial fibrillation (AF) is an important contributor to cryptogenic stroke, yet remains difficult to unmask at presentation. This study investigated the predictive value of left atrial (LA) mechanics by strain echocardiography during stroke hospitalization for the presence of AF as detected on early 30-day monitoring and routine clinical follow-up.
Methods
Left atrial mechanics were studied by strain echocardiography in a retrospective cohort of 191 patients with cryptogenic stroke and 30-day mobile cardiac outpatient telemetry poststroke to diagnose AF. After this, AF was diagnosed via routine clinical follow-up. The independent and incremental value of measures of LA size and mechanics (i.e., strain and strain rate in the reservoir, conduit, and booster pump phase) to predict AF on top of clinical characteristics was assessed.
Results
Of 191 patients, 15% (n = 28) developed AF, of which 10 were observed during 30-day mobile cardiac outpatient telemetry and 18 were observed at a median follow-up of 25 (interquartile range, 10-43) months. Median time from embolic stroke to strain echocardiography was 1 day (interquartile range, 1-2 days). Left atrial mechanics were significantly worse in AF (P < .05 for all), despite largely similar baseline cardiovascular risk profile. Booster pump strain rate was the strongest predictor for AF, independent of age, LA volume index, E/e\', and reservoir strain (odds ratio = 2.88 per SD increase; 95% confidence interval, 1.29-6.41; P = .010). Adding LA strain reservoir strain and booster pump function significantly enhanced a multivariate model to predict AF. Freedom from AF was significantly lower in subjects with a booster pump strain rate (at stroke presentation) worse than -0.67 sec-1, as derived from receiver operator curve analysis (P < .001).
Conclusions
Left atrial mechanics and particularly the LA booster pump function assessed early during hospitalization for cryptogenic stroke can identify patients at greater likelihood of future diagnosis of AF. These findings could in part relate to LA mechanical stunning after spontaneous cardioversion, which-when identified by early strain echocardiography-can inform further risk stratification and decision-making.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:156-165
Deferm S, Bertrand PB, Churchill TW, Sharma R, ... Schwamm LH, Yoerger Sanborn DM
J Am Soc Echocardiogr: 30 Jan 2021; 34:156-165 | PMID: 33132019
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Abstract

Feasibility, Reproducibility, and Clinical Implications of the Novel Fully Automated Assessment for Global Longitudinal Strain.

Kawakami H, Wright L, Nolan M, Potter EL, Yang H, Marwick TH
Background
Despite evidence of its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine, because it requires proficiency and is time consuming. Automated assessment of GLS may be the solution for this situation. The aim of this study was to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semiautomated and manual assessment of GLS.
Methods
In this validation study, different methods for the assessment of GLS were applied to echocardiograms from 561 asymptomatic subjects (mean age, 71 ± 5 years) with heart failure risk factors, recruited from the community. All patients had both data on follow-up outcomes (new heart failure and cardiac death) and interpretable echocardiographic images for strain analysis. Measurement of GLS was repeated using the same apical images with three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semiautomated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator).
Results
AutoStrain measurements were technically feasible in 99.5% of patients. Calculation times for automated (0.5 ± 0.1 min/patient) and semiautomated assessment (2.7 ± 0.6 min/patient) were significantly shorter than for manual assessment (4.5 ± 1.6 min/patient; P < .001 for both). Approximately 40% of patients were thought to need manual correction after automatic calculation of GLS. Therefore, there was considerable discordance between automated and semiautomated and manual GLS. Over a median of 12 months of follow-up, cardiovascular events (new heart failure and cardiac death) occurred in 66 patients (11.8%). Automated GLS showed the potential to correctly detect normal and abnormal systolic function and predict cardiac events; the predictive value was inferior to that of semiautomated GLS.
Conclusions
A novel fully automated assessment for GLS may provide a technically feasible, rapidly reproducible, and clinically applicable means of assessing left ventricular function, but a substantial number of automatic traces still need manual correction by experts. At the present stage, the semiautomated approach using this novel automated software seems to provide a better balance between feasibility and clinical relevance.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:136-145.e2
Kawakami H, Wright L, Nolan M, Potter EL, Yang H, Marwick TH
J Am Soc Echocardiogr: 30 Jan 2021; 34:136-145.e2 | PMID: 33293202
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Abstract

Effects of an Electronic Medical Record Intervention on Appropriateness of Transthoracic Echocardiograms: A Prospective Study.

Chen W, Saxon DT, Henry MP, Herald JR, ... Gurm HS, Bhave NM
Background
Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders.
Methods
This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography.
Results
Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005).
Conclusions
The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:176-184
Chen W, Saxon DT, Henry MP, Herald JR, ... Gurm HS, Bhave NM
J Am Soc Echocardiogr: 30 Jan 2021; 34:176-184 | PMID: 33139140
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Abstract

Prognostic Value of the Right Ventricular Ejection Fraction, Assessed by Fully Automated Three-Dimensional Echocardiography: A Direct Comparison of Analyses Using Right Ventricular-Focused Views versus Apical Four-Chamber Views.

Namisaki H, Nabeshima Y, Kitano T, Otani K, Takeuchi M
Background
Right ventricular (RV) three-dimensional echocardiographic (3DE) data sets are acquired from either the RV-focused view (RVFV) or the apical four-chamber view (4CV). The prognostic value of 3DE RV ejection fraction (RVEF) was investigated using fully automated RV quantification software, and how measurement values with 3DE data sets from the RVFV compare with those from the 4CV was determined.
Methods
One hundred seventy-four patients who had undergone both cardiac magnetic resonance (CMR) and 3DE imaging were retrospectively selected. RV 3DE data sets were acquired from both the RVFV and the 4CV and were analyzed separately using fully automated RV quantification software. Primary end points were cardiac events, including cardiac death, heart failure requiring hospitalization, nonfatal myocardial infarction, and ventricular tachyarrhythmia.
Results
The feasibility of RVEF measurements on 3DE imaging from the RVFV and 4CV was 92% and 92%, respectively. There was good correlation (r = 0.83) and small bias (0.3%) between RVEF from the RVFV and that from the 4CV. Similar results were obtained when only data from patients whose echocardiograms had poor image quality in one or both views were analyzed (r = 0.83, bias = 1.7%, n = 78). Although fully automated analysis in both the RVFV and 4CV significantly underestimated RV volumes compared with CMR, neither measurement differed significantly for RVEF compared with CMR. During a median follow-up period of 12.5 months, 21 patients experienced primary end points. RVEF assessed by CMR and 3DE imaging was significantly associated with cardiac events. RVEF using fully automated analysis had a significant association with cardiac events, even in patients with poor image quality (RVFV: hazard ratio, 0.90 [P = .009, n = 44]; 4CV: hazard ratio, 0.90 [P = .009, n = 68]).
Conclusions
RV 3DE data sets from the RVFV and 4CV yielded similar RVEF values using fully automated software. RVEFs from both approaches had significant association with outcomes. Thus, both provide accurate information regarding RV function and risk for adverse outcomes.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:117-126
Namisaki H, Nabeshima Y, Kitano T, Otani K, Takeuchi M
J Am Soc Echocardiogr: 30 Jan 2021; 34:117-126 | PMID: 33153858
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Impact:
Abstract

Pediatric Heart Network Echocardiographic Z Scores: Comparison with Other Published Models.

Lopez L, Frommelt PC, Colan SD, Trachtenberg FL, ... LuAnn Minich L, Pediatric Heart Network Investigators
Background
Different methods have resulted in variable Z scores for echocardiographic measurements. Using the measurements from 3,215 healthy North American children in the Pediatric Heart Network (PHN) echocardiographic Z score database, the authors compared the PHN model with previously published Z score models.
Methods
Z scores were derived for cardiovascular measurements using four models (PHN, Boston, Italy, and Detroit). Model comparisons were performed by evaluating (1) overlaid graphs of measurement versus body surface area with curves at Z = -2, 0, and +2; (2) scatterplots of PHN versus other Z scores with correlation coefficients; (3) Bland-Altman plots of PHN versus other Z scores; and (4) comparison of median Z scores for each model.
Results
For most measurements, PHN Z score curves were similar to Boston and Italian curves but diverged from Detroit curves at high body surface areas. Correlation coefficients were high when comparing the PHN model with the others, highest with Boston (mean, 0.99) and lowest with Detroit (mean, 0.90). Scatterplots suggested systematic differences despite high correlations. Bland-Altman plots also revealed poor agreement at both extremes of size and a systematic bias for most when comparing PHN against Italian and Detroit Z scores. There were statistically significant differences when comparing median Z scores between the PHN and other models.
Conclusions
Z scores from the multicenter PHN model correlated well with previous single-center models, especially the Boston model, which also had a large sample size and similar methodology. The Detroit Z scores diverged from the PHN Z scores at high body surface area, possibly because there were more subjects in this category in the PHN database. Despite excellent correlation, significant differences in Z scores between the PHN model and others were seen for many measurements. This is important when comparing publications using different models and for clinical care, particularly when Z score thresholds are used to guide diagnosis and management.

Copyright © 2020 American Society of Echocardiography. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:185-192
Lopez L, Frommelt PC, Colan SD, Trachtenberg FL, ... LuAnn Minich L, Pediatric Heart Network Investigators
J Am Soc Echocardiogr: 30 Jan 2021; 34:185-192 | PMID: 33189460
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Impact:
Abstract

Combined Echocardiographic and Cardiopulmonary Exercise to Assess Determinants of Exercise Limitation in Chronic Obstructive Pulmonary Disease.

Rozenbaum Z, Ben-Gal Y, Kapusta L, Hochstadt A, ... Keren G, Topilsky Y
Background
Current methods do not allow a thorough assessment of causes associated with limited exercise capacity in patients with chronic obstructive pulmonary disease (COPD).
Methods
Twenty patients with COPD and 20 matched control subjects were assessed using combined cardiopulmonary and stress echocardiographic testing. Various echocardiographic parameters (left ventricular [LV] volumes, right ventricular [RV] area, ejection fraction, stroke volume, S\', and E/e\' ratio) and ventilatory parameters (peak oxygen consumption [Vo2] and A-Vo2 difference) were measured to evaluate LV and RV function, hemodynamics, and peripheral oxygen extraction (A-VO2 difference).
Results
Significant differences (both between groups and for group-by-time interaction) were seen in exercise responses (LV volume, RV area, LV volume/RV area ratio, S\', E/e\' ratio, tricuspid regurgitation grade, heart rate, stroke volume, and Vo2). The major mechanisms of reduced exercise tolerance in patients with COPD were bowing of the septum to the left in 12 (60%), abnormal increases in E/e\' ratio in 12 (60%), abnormal stroke volume reserve in 16 (80%), low peak A-Vo2 difference in 10 (50%), chronotropic incompetence in 13 (65%), or a combination of several mechanisms. Patients with COPD and poor exercise tolerance showed attenuated increases in stroke volume, heart rate, and A-Vo2 difference and exaggerated changes in LV/RV ratio and LV compliance (ratio of LV volume to E/e\' ratio) compared with patients with COPD with good exercise tolerance.
Conclusions
Combined cardiopulmonary and stress echocardiographic testing can be helpful in determining individual mechanisms of exercise intolerance in patients with COPD. In patients with COPD, exercise intolerance is predominantly the result of chronotropic incompetence, limited stroke volume reserve, exercise-induced elevation in left filling pressure, and peripheral factors and not simply obstructive lung function. Limited stroke volume is related to abnormal RV contractile reserve and reduced LV compliance introduced through septal flattening and direct ventricular interaction.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:146-155.e5
Rozenbaum Z, Ben-Gal Y, Kapusta L, Hochstadt A, ... Keren G, Topilsky Y
J Am Soc Echocardiogr: 30 Jan 2021; 34:146-155.e5 | PMID: 33187814
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Impact:
Abstract

Usefulness of Stress Echocardiography in the Management of Patients Treated with Anticancer Drugs.

Novo G, Santoro C, Manno G, Di Lisi D, ... Cameli M, Galderisi M
In recent years, the survival of patients with cancer has improved thanks to advances in antineoplastic therapeutic protocols. This has led to an increasing burden of cardiovascular complications related to cancer treatment. Therefore, a new branch of cardiology has been created, \"cardio-oncology,\" with the aims of preventing cardiovascular complications related to antineoplastic treatment, achieving early diagnosis and treatment of any complications, and allowing completion of the expected antineoplastic treatment. Stress echocardiography has a pivotal role in achieving a timely diagnosis of coronary artery disease and thus is the best management approach in this clinical setting. Atherosclerotic processes can be exacerbated by both chemotherapy and chest irradiation in patients with cancer, even several years after anticancer treatment completion. Moreover, stress echocardiography has many other potential applications, such as in the evaluation of subclinical left ventricular dysfunction and contractile reserve in patients treated with anticancer drugs that have the potential to induce myocardial damage, as well as evaluating valve disease. The objective of this review is to delineate the role of stress echocardiography in cardio-oncology.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:107-116
Novo G, Santoro C, Manno G, Di Lisi D, ... Cameli M, Galderisi M
J Am Soc Echocardiogr: 30 Jan 2021; 34:107-116 | PMID: 33223357
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Impact:
Abstract

Left Atrial Strain Is the Best Predictor of Adverse Cardiovascular Outcomes in Patients with Chronic Kidney Disease.

Gan GCH, Kadappu KK, Bhat A, Fernandez F, ... Eshoo S, Thomas L
Background
Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events, which is underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients.
Methods
Two hundred forty-three prospectively recruited stage 3/4 CKD patients (male, 63%; mean age, 59.2 ± 14.4 years) without previous cardiac disease made up the study cohort. All participants underwent a transthoracic echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for 3.9 ± 2.7 years for the primary end point of cardiovascular death and major adverse cardiovascular event (MACE). The secondary end point was the composite of all-cause death and MACE.
Results
Fifty-four patients met the primary end point, and 65 the secondary end point. On log-rank tests, older age, diabetes mellitus, anemia, greater LV mass, reduced LV global longitudinal strain, larger indexed LA volume, higher E/e\' ratio, and reduced LA reservoir strain (LASr; P < .01 for all) were independent predictors of cardiovascular death and MACE. On multivariable regression analysis of univariate predictors, LASr (P < .01) was the only independent predictor for the primary end point as well as for the secondary end point. Receiver operating characteristic curve analysis showed LASr was a stronger predictor of adverse events (area under the curve [AUC] = 0.84) compared to the Framingham (AUC = 0.58) and Atherosclerotic Cardiovascular Disease (AUC = 0.59) risk scores.
Conclusions
LASr is an independent predictor of cardiovascular death and MACE in CKD patients, superior to clinical risk scores, LV parameters, and LA volume.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2021; 34:166-175
Gan GCH, Kadappu KK, Bhat A, Fernandez F, ... Eshoo S, Thomas L
J Am Soc Echocardiogr: 30 Jan 2021; 34:166-175 | PMID: 33223356
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Impact:
Abstract

Characterization of Responder Profiles for Cardiac Resynchronization Therapy through Unsupervised Clustering of Clinical and Strain Data.

Gallard A, Bidaut A, Hubert A, Sade E, ... Hernandez A, Donal E
Background
The mechanisms of improvement of left ventricular (LV) function with cardiac resynchronization therapy (CRT) are not yet elucidated. The aim of this study was to characterize CRT responder profiles through clustering analysis, on the basis of clinical and echocardiographic preimplantation data, integrating automatic quantification of longitudinal strain signals.
Methods
This was a multicenter observational study of 250 patients with chronic heart failure evaluated before CRT device implantation and followed up to 4 years. Clinical, electrocardiographic, and echocardiographic data were collected. Regional longitudinal strain signals were also analyzed with custom-made algorithms in addition to existing approaches, including myocardial work indices. Response was defined as a decrease of ≥15% in LV end-systolic volume. Death and hospitalization for heart failure at 4 years were considered adverse events. Seventy features were analyzed using a clustering approach (k-means clustering).
Results
Five clusters were identified, with response rates between 50% in cluster 1 and 92.7% in cluster 5. These five clusters differed mainly by the characteristics of LV mechanics, evaluated using strain integrals. There was a significant difference in event-free survival at 4 years between cluster 1 and the other clusters. The quantitative analysis of strain curves, especially in the lateral wall, was more discriminative than apical rocking, septal flash, or myocardial work in most phenogroups.
Conclusions
Five clusters are described, defining groups of below-average to excellent responders to CRT. These clusters demonstrate the complexity of LV mechanics and prediction of response to CRT. Automatic quantitative analysis of longitudinal strain curves appears to be a promising tool to improve the understanding of LV mechanics, patient characterization, and selection for CRT.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 28 Jan 2021; epub ahead of print
Gallard A, Bidaut A, Hubert A, Sade E, ... Hernandez A, Donal E
J Am Soc Echocardiogr: 28 Jan 2021; epub ahead of print | PMID: 33524492
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Abstract

Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis.

Oguz D, Padang R, Rashedi N, Pislaru SV, ... Rihal CS, Thaden JJ
Background
Iatrogenic mitral stenosis is a known limitation of transcatheter edge-to-edge mitral valve repair (TMVr), but determinants of increased postprocedural mean diastolic gradient (MG) are not well defined. The aim of this study was to determine correlates of increased post-TMVr MG or aborted clip implantation due to increased MG.
Methods
Procedural three-dimensional transesophageal echocardiographic (TEE) data sets of 112 patients who underwent TMVr were retrospectively analyzed. Three-dimensional TEE mitral valve area (MVA) planimetry and mitral annular calcification (MAC) were quantified using multiplanar reconstruction. When MAC extension into the mitral leaflets was present, MAC with leaflet calcification (MAC-LC) length was recorded as the maximum distance from the mitral annulus to the most distal leaflet calcification. Increased MG after TMVr, measured on intraprocedural TEE imaging, was defined as ≥5 mm Hg or aborted clip implantation due to increased MG.
Results
Baseline MVA was 5.9 ± 1.7 cm2, baseline MG was 2.1 ± 1.2 mm Hg, and MAC-LC length was 4.0 ± 4.5 mm. Thirty-two patients (29%) had increased post-TMVr MG. Risk for increased post-TMVr MG was 86%, 28%, and 14% in patients with baseline MVA < 4.0, 4.0 to 6.0, and >6.0 cm2, respectively (P < .001). In patients with baseline MVA 4.0 to 6.0 cm2, concurrent baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm was associated with higher risk for increased post-TMVr MG (53% vs 12%, P = .002). In patients with baseline MVA < 4.0 and >6.0 cm2, the risk for increased post-TMVr MG was similar in the presence or absence of baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm (P > .05 for both).
Conclusions
Patients with baseline three-dimensional TEE MVA < 4.0 cm2 are at high risk for increased post-TMVr MG. Additionally, patients with borderline MVA (4.0-6.0 cm2) and concurrent MAC-LC length ≥ 6 mm or baseline MG ≥ 4 mm Hg are at moderate risk for increased MG after TMVr.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 28 Jan 2021; epub ahead of print
Oguz D, Padang R, Rashedi N, Pislaru SV, ... Rihal CS, Thaden JJ
J Am Soc Echocardiogr: 28 Jan 2021; epub ahead of print | PMID: 33524491
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Abstract

ASE Statement on Adapting Pediatric, Fetal, and Congenital Heart Disease Echocardiographic Services to the Evolving COVID-19 Pandemic.

Altman CA, Donofrio MT, Arya B, Wasserman M, ... Swaminathan M, Barker PCA
Over the 12 months since the start of the coronavirus disease 2019 pandemic, an explosion of investigation and an increase in experience have led to vast improvement in our knowledge about this disease. However, coronavirus disease 2019 remains a huge public health threat.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 27 Jan 2021; epub ahead of print
Altman CA, Donofrio MT, Arya B, Wasserman M, ... Swaminathan M, Barker PCA
J Am Soc Echocardiogr: 27 Jan 2021; epub ahead of print | PMID: 33516940
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Abstract

Exercise-Induced Cardiac Fatigue after a 45-min Bout of High-Intensity Running Exercise Is Not Altered under Hypoxia.

Kleinnibbelink G, van Dijk APJ, Fornasiero A, Speretta GF, ... Thijssen DHJ, Oxborough DL
Background
Acute exercise promotes transient exercise-induced cardiac fatigue, which affects the right ventricle and to a lesser extent the left ventricle. Hypoxic exposure induces an additional increase in right ventricular (RV) afterload. Therefore, exercise in hypoxia may differently affect both ventricles. The aim of this study was to investigate the acute effects of a bout of high-intensity exercise under hypoxia versus normoxia in healthy individuals on right- and left-sided cardiac function and mechanics.
Methods
Twenty-one healthy individuals (mean age, 22.2 ± 0.6 years; 14 men) performed 45-min high-intensity running exercise under hypoxia (fraction of inspired oxygen 14.5%) and normoxia (fraction of inspired oxygen 20.9%) in a randomized order. Pre- and post-exercise echocardiography, at rest and during low-to-moderate intensity recumbent exercise (\"stress\"), was performed to assess RV and left ventricular (LV) cardiac function and mechanics. RV structure, function, and mechanics were assessed using conventional two-dimensional, Doppler, tissue Doppler, speckle-tracking echocardiographic, and novel strain-area loops.
Results
Indices of RV systolic function (RV fractional area change, Tricuspid annular plane systolic excursion, RV s\', and RV free wall strain) and LV function (LV ejection fraction and LV global longitudinal strain) were significantly reduced after high-intensity running exercise (P < .01). These exercise-induced changes were more pronounced when echocardiography was examined during stress compared with baseline. These responses in RV and LV indices were not altered under hypoxia (P > .05).
Conclusions
There was no impact of hypoxia on the magnitude of exercise-induced cardiac fatigue in the right and left ventricles after a 45-min bout of high-intensity exercise. This finding suggests that any potential increase in loading conditions does not automatically exacerbate exercise-induced cardiac fatigue in this setting.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 26 Jan 2021; epub ahead of print
Kleinnibbelink G, van Dijk APJ, Fornasiero A, Speretta GF, ... Thijssen DHJ, Oxborough DL
J Am Soc Echocardiogr: 26 Jan 2021; epub ahead of print | PMID: 33333146
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Abstract

Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery.

MacKay EJ, Zhang B, Heng S, Ye T, ... Desai ND, Groeneveld PW
Background
Coronary artery bypass graft (CABG) surgery is the most widely performed cardiac surgery in the United States. Transesophageal echocardiography (TEE) is frequently used in a variety of cardiac surgical procedures, but its clinical benefit in isolated CABG surgery is unclear, and guidelines remain indeterminate. The aim of this study was to compare clinical outcomes among patients undergoing isolated CABG surgery with versus without TEE in order to test the hypothesis that TEE would be associated with improved clinical outcomes after CABG surgery.
Methods
A matched retrospective cohort study was conducted among Medicare beneficiaries undergoing isolated CABG surgery with versus without intraoperative monitoring using TEE in the United States. The primary analysis was a near/far instrumental variable match that paired hospitals with similar characteristics and patient populations but with opposing probabilities for using TEE in CABG surgery. Outcomes included 30-day mortality, a composite outcome of stroke or 30-day mortality, length of hospitalization, and incidence of esophageal perforation.
Results
Of 114,871 patients undergoing isolated CABG surgery, 65,471 (57%) underwent TEE and 49,400 (43%) did not. Hospital-level instrumental variable matched analysis demonstrated that among the subset of 968 matched hospitals, TEE receipt was associated with lower 30-day mortality (3.7% vs 4.9%, P < .001), a lower incidence of the composite outcome of stroke or 30-day mortality (4.5% vs 5.6%, P < .001), no difference in length of hospitalization (10.32 vs 10.52 days, P = .26), and no difference in the incidence of esophageal perforation (0.01% vs 0.01%, P = .63). These results were replicated in surgeon-level and patient-level matched-pair instrumental variable analyses, and all analyses were robust to sensitivity analyses that tested for biases introduced by unmeasured confounding.
Conclusions
The findings from this study suggest that TEE may offer a clinical benefit to cardiac surgical patients undergoing isolated CABG surgery.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 25 Jan 2021; epub ahead of print
MacKay EJ, Zhang B, Heng S, Ye T, ... Desai ND, Groeneveld PW
J Am Soc Echocardiogr: 25 Jan 2021; epub ahead of print | PMID: 33508414
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Abstract

Application of Guideline-Based Echocardiographic Assessment of Left Atrial Pressure to Heart Failure with Preserved Ejection Fraction.

Rethy L, Borlaug BA, Redfield MM, Oh JK, Shah SJ, Patel RB
Background
Early, noninvasive identification of patients with heart failure with preserved ejection fraction (HFpEF) with congestion may allow timely tailoring of decongestive therapies. The 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines provide an algorithm to assess for elevated left atrial pressure (LAP); the associations of echocardiographic LAP with clinical status and disease progression in patients with HFpEF are unclear.
Methods
Participants in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF trial were categorized into one of four prespecified guideline-based echocardiographic LAP categories: (1) normal, (2) elevated, (3) atrial fibrillation (AF) at the time of echocardiography, or (4) indeterminate. Associations of echocardiographic LAP categories with baseline exercise capacity, change in exercise capacity, and change in N-terminal pro-B-type natriuretic peptide over 24 weeks were evaluated.
Results
Of 216 participants, 199 underwent mitral inflow Doppler echocardiography for LAP categorization. Participants with elevated echocardiographic LAP (n = 81) or AF (n = 57) were older and had a higher prevalence of kidney dysfunction. Compared with the normal echocardiographic LAP group (n = 28), elevated echocardiographic LAP and AF were each independently associated with a greater reduction in peak oxygen consumption over 24 weeks after adjusting for baseline values and clinical covariates (β for elevated echocardiographic LAP = -1.55 [95% CI, -2.59 to -0.51], P = .004; β for AF = -1.33 [95% CI, -2.49 to -0.17], P = .03). Indeterminate echocardiographic LAP (n = 33) was also independently associated with a reduction in exercise capacity at 24 weeks compared with normal echocardiographic LAP (β = -1.35; 95% CI, -2.51 to -0.19; P = .02). Finally, elevated echocardiographic LAP and AF were significantly associated with increases in N-terminal pro-B-type natriuretic peptide over 24 weeks compared with normal echocardiographic LAP.
Conclusions
In patients with chronic HFpEF, elevated echocardiographic LAP and indeterminate echocardiographic LAP, as defined by contemporary guidelines, and AF were each independently associated with a reduction in exercise capacity compared with normal echocardiographic LAP. These findings suggest the potential utility of noninvasive LAP assessment in patients with HFpEF for tailoring treatments that decrease congestion.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 19 Jan 2021; epub ahead of print
Rethy L, Borlaug BA, Redfield MM, Oh JK, Shah SJ, Patel RB
J Am Soc Echocardiogr: 19 Jan 2021; epub ahead of print | PMID: 33359021
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This program is still in alpha version.