Journal: J Am Soc Echocardiogr

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Abstract

Systematic fluoroscopic-echocardiographic fusion imaging protocol for transcatheter edge-to-edge mitral valve repair intraprocedural monitoring.

Melillo F, Fisicaro A, Stella S, Ancona F, ... Colombo A, Agricola E
Background
Whether fluoroscopic-echocardiographic fusion imaging (FI) might represent an added value for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair (TMVr) is yet unknown and few data exist regarding safety and feasibility of the novel technology.
Methods
The aim of this single-centre study was to test and validate a FI protocol for intraprocedural monitoring of TMVr and assess its clinical usefulness. Eighty patients underwent MitraClip procedure using FI guidance (FI+) for either degenerative (DMR) (35%) or functional (FMR) (65%) mitral regurgitation and were compared to the last 80 patients before FI introduction treated with conventional echo and fluoroscopic monitoring (FI-).
Results
The number of patients treated for FMR and DMR was similar between FI+ and FI- group, as well as the number of devices implanted (1.51±0.5 vs. 1.58±0.6; p=0.46). Prevalence of complex mitral anatomy for percutaneous repair was high (32.5%, up to 39.2% in the hybrid arm). Fluoroscopy time was significantly lower in FI+ patients (37.3±14.6 vs. 48.3±28.3 min; p=0.003), but not kerma area product (91.5±74.1 vs. 108.8±105.0 Gy cm; p=0.23) or procedural time (92.2±36.1 vs. 103.1±42.7 min; p=0.086). After adjusting for confounding factors (XT device and complex anatomy), fusion imaging reduced fluoroscopy time (coeff -10.4 min; 95% CI -18.03 - -2.82; p=0.007) and improved procedural success at the end of the procedure (OR 2.87 95% CI 1.00 - 8.24, p=0.049) and discharge (OR 2.24, 95% CI 1.04 - 4.80; p=0.039). Peri-procedural complications rate was similar in both groups (8.9% vs. 13.0%; p=0.40).
Conclusions
Our study described the systematic use of a FI protocol for intraprocedural guidance during TMVr demonstrating a reduction of the fluoroscopy time and improvement in procedural success in a population with high prevalence of challenging mitral anatomy for percutaneous repair.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 12 Jan 2021; epub ahead of print
Melillo F, Fisicaro A, Stella S, Ancona F, ... Colombo A, Agricola E
J Am Soc Echocardiogr: 12 Jan 2021; epub ahead of print | PMID: 33453367
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Abstract

Cardiovascular dysfunction in children exposed to preeclampsia during fetal life.

Hoodbhoy Z, Mohammed N, Rozi S, Aslam N, ... Chowdhury D, Hasan BS
Objective
Keeping in view the Developmental Origin of Health and Disease hypothesis, this study aimed to assess differences in cardiac and vascular structure and function in children exposed to preeclampsia in-utero as compared to those of normotensive mothers. We hypothesized that children exposed to preeclampsia had altered cardiac and vascular structure and function as compared to the unexposed group.
Methods
This was a retrospective cohort study which included children between 2-10 years of age born to mothers with and without exposure to preeclampsia in-utero (n= 80 in each group). Myocardial morphology and function using echocardiogram and carotid intima-media thickness and pulse wave velocity were performed. Multivariable linear regression was used to compare preeclampsia exposed and non-exposed groups. Subgroup analysis to assess differences between early vs late onset preeclampsia was also performed.
Results
Forty one percent (n=33) mothers had early onset preeclampsia. Children in the exposed group had significantly higher prevalence of Stage 1 systolic and diastolic hypertension (22%, n=18 and 35%, n=18 respectively) as compared to the unexposed group (9%, n=7 and 19% n =15 respectively, p=0.01). Children in the exposed group also had higher pulse wave velocity as compared to unexposed group (0.42 +/- 0.1 vs 0.39 +/- 0.1, p=0.03). Subgroup analysis revealed that blood pressure and pulse wave velocity changes were primarily determined by early onset preeclampsia. There was no significant difference in cardiac morphology or systolic and diastolic function between the exposed and unexposed groups.
Conclusion
In-utero exposure to preeclampsia has an effect on the vascular function in children aged 2-10 years, primarily related to early onset disease. Routine blood pressure screening should be recommended for such children.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 12 Jan 2021; epub ahead of print
Hoodbhoy Z, Mohammed N, Rozi S, Aslam N, ... Chowdhury D, Hasan BS
J Am Soc Echocardiogr: 12 Jan 2021; epub ahead of print | PMID: 33453366
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Abstract

The pathophysiological link between right atrial remodeling and functional tricuspid regurgitation in patients with atrial fibrillation. A three-dimensional echocardiography study.

Guta AC, Badano LP, Tomaselli M, Mihalcea D, ... Parati G, Muraru D
Background
Atrial fibrillation (AF) itself may lead to functional tricuspid regurgitation (FTR) through tricuspid annulus (TA) dilation. However, the pathophysiological determinants of TA enlargement in AF patients remain to be clarified. The objectives of this study were: i. to compare the TA size and function in AF patients versus healthy subjects; ii. to identify the determinants of TA remodeling in patients with AF and FTR; iii. to assess the relationships among right heart structures and severity of FTR in AF patients.
Methods
Eighty-three consecutive patients with long-term persistent AF and FTR (61±9.9 years, 67% women) were prospectively enrolled and compared with 83 sex and body surface area matched healthy subjects. Heart chamber size and function, and TA geometry were analyzed using three-dimensional echocardiography.
Results
Among AF patients, 33%, 34% and 33% had mild, moderate and severe FTR, respectively. Right atrial (RA) dilation was detected in 93% of AF patients, while only 27% and 12% of them showed dilated or dysfunctional right ventricle (RV), respectively. End-diastolic TA area had the strongest correlation with the minimum volume of the RA (RAVmin r=0.6981, p<0.0001), but only mild correlation with RV end-diastolic volume and sex (r=0.3405, p=0.0019; r=0.2914, p=0.0075). At multivariable analysis, only RAVmin was independently associated with TA area in AF patients (r=0.665, p<0.0001). RAVmin and TA area were the only predictors of FTR severity.
Conclusions
In patients with AF, RA dilation seems to be more important than RV dilation to determine TA enlargement and subsequent FTR development. RAVmin and TA area were directly correlated to FTR severity.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 09 Jan 2021; epub ahead of print
Guta AC, Badano LP, Tomaselli M, Mihalcea D, ... Parati G, Muraru D
J Am Soc Echocardiogr: 09 Jan 2021; epub ahead of print | PMID: 33440232
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Abstract

Diagnosis of coronary artery abnormalities in patients with Kawasaki disease according to established guidelines and Z score formulas.

Kim SH, Kim JY, Kim GB, Yu JJ, Choi JW
Background:
and objectives
The diagnosis of coronary artery abnormalities (CAA), including dilation and aneurysm, in Kawasaki disease is paramount to treatment planning. CAA is defined using various standards, which makes diagnosis difficult. We determined the variability of CAA prevalence according to existing guidelines and Z scores formulas and examined the discrepancies in widely used Z score formulas.
Materials and methods
Using data from the Korean national survey on Kawasaki Disease, we included and analyzed 6889 cases. We compared the overall prevalence of CAA and the prevalence for subgroups based on aneurysm severity, age, and body surface area. Finally, we evaluated the discrepancies among the five Z score formulas by comparing two of the formulas in pairs.
Results
According to the Japanese criteria, the prevalence of CAA was 18%. According to the AHA (American Heart Association) criteria, the prevalence of dilation or aneurysm was ∼21-42%, and that of the aneurysm of the left anterior descending artery (LAD) or right coronary artery (RCA) was ∼8-27%. The prevalence of CAA and that of LAD or RCA was significantly different with discrepancies between the Japanese and AHA Z score criteria, as well as that among the five Z score formulas. Additionally, misclassification of aneurysm severity was observed between each criterion or Z score formula. The calculated Z scores showed significant variation among them. The more extreme the Z score values, the more discrepancy we observed.
Conclusion
Different guidelines and Z score formulas yield significantly different CAA prevalences and classifications. In addition, we observed more discrepancies with higher Z score values. Since CAA or aneurysm severity could be changed by guidelines or Z score formulas, we need to choose them carefully, and if one formula is chosen, consistency is needed.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Jan 2021; epub ahead of print
Kim SH, Kim JY, Kim GB, Yu JJ, Choi JW
J Am Soc Echocardiogr: 06 Jan 2021; epub ahead of print | PMID: 33422668
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Abstract

Importance of systematic right ventricular assessment in cardiac resynchronization therapy candidates: a machine-learning approach.

Galli E, Le Rolle V, Smiseth OA, Duchenne J, ... Voigt JU, Donal E
Background
Despite all having systolic heart failure and broad QRS, patients screened for cardiac resynchronization therapy (CRT) are highly heterogeneous, and it remains extremely challenging to predict the impact of the device on left ventricular (LV) function and outcomes.
Objectives
We sought to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular (LV) remodeling and prognosis of CRT-candidates by the application of machine learning (ML) approaches.
Methods
193 patients with systolic heart failure undergoing CRT according to current recommendations were prospectively included in this multicentre study. We used a combination of the Boruta algorithm and random forest methods to identify features predicting both CRT volumetric response and prognosis. The model performance was tested by the area under the receiver operating curve (AUC). We also applied the K-medoid method to identify clusters of phenotypically similar patients.
Results
From 28 clinical, electrocardiographic, and echocardiographic-derived variables, 16 features were predictive of CRT response, and 11 features were predictive of prognosis. Among the predictors of CRT-response, 8 variables (50%) pertained to right ventricular (RV) size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with a particularly good prediction of both CRT response (AUC 0.81, 95% CI: 0.74-0.87) and outcomes (AUC 0.84, 95% CI: 0.75-0.93). An unsupervised ML approach allowed the identifications of two phenogroups of patients who differed significantly in clinical variables and parameters of biventricular size, and RV function. The two phenogroups had significant different prognosis (HR 4.70, 95% CI: 2.1-10.0, p<0.0001; log-rank p<0.0001).
Conclusions
Machine learning can reliably identify clinical and echocardiographic features associated with CRT-response and prognosis. The evaluation of both RV-size and function parameters has pivotal importance for the risk stratification of CRT-candidates and should be systematically assessed in patients undergoing CRT.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Jan 2021; epub ahead of print
Galli E, Le Rolle V, Smiseth OA, Duchenne J, ... Voigt JU, Donal E
J Am Soc Echocardiogr: 06 Jan 2021; epub ahead of print | PMID: 33422667
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Abstract

Reference Values of Carotid Ultrafast Pulse Wave Velocity: A Prospective, Multicenter Population-Based Study.

Ma CY, Wang S, Wang YH, Meng PP, ... Ren WD,
Background
Ultrafast ultrasound imaging has been demonstrated to be an effective method to evaluate carotid stiffness through carotid pulse wave velocity (PWV) with high reproducibility, but lack of reference values has precluded its widespread use in clinical practice. This study aimed to establish reference values of PWV for ultrafast ultrasound imaging in a prospective, multicenter, population-based cohort study and to investigate the main determinants of carotid PWV.
Methods
A total of 1,544 healthy Han Chinese volunteers (581 [38%] men; age, 18-95 years) were enrolled from 32 collaborating laboratories in China. The participants were categorized by age, blood pressure (BP), and body mass index (BMI). The basic clinical parameters and the carotid PWV at the beginning of systole (BS) and end of systole (ES) were measured via ultrafast ultrasound imaging techniques.
Results
The PWV at both BS and ES was significantly higher in the left carotid artery than in the right carotid artery. The PWV at BS was significantly higher in men than in women; however, no significant difference was noted in the PWV at ES between men and women. Multiple linear regression analyses revealed that age, BP, and BMI were independently correlated with the PWV at both BS and ES. The PWV at BS and ES progressively increased with increase in age, BP, and BMI. Further, the age- and sex-specific reference values of carotid PWV for ultrafast ultrasound imaging were established.
Conclusions
Reference values of carotid PWV for ultrafast ultrasound imaging, stratified by sex and age, were determined for the first time. Age, BP, and BMI were the dominant determinants of carotid PWV for ultrafast ultrasound imaging, which should be considered in clinical practice for assessing arterial stiffness.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Jan 2021; epub ahead of print
Ma CY, Wang S, Wang YH, Meng PP, ... Ren WD,
J Am Soc Echocardiogr: 06 Jan 2021; epub ahead of print | PMID: 33422666
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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 echocardiography (STE) 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. We aimed 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 comprising 41 control subjects (mean age 40±12 years; male gender 49%) and 39 patients with cardiac disease (mean age 47±15 years; male gender 92%) were examined by 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 (GLS), endocardial GLS (GLS) and transmural global circumferential strain (GCS), epicardial GCS (GCS), endocardial GCS (GCS) in addition to epi-endocardial gradients. Bland-Altman plots and Pearson\'s correlation coefficients were used to evaluate the 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 1.4±1.5% and 1.5±2.0% (p<0.001) in control subjects, and 0.9±1.8% and 0.9±1.9% (p<0.001) in patients with cardiac disease. STE and CMR-FT GCS increased 2.0±2.2% and 1.8±2.3%-point (p<0.001) in control subjects, and 1.8±2.3% and 1.7±3.6% in patients with cardiac disease (p<0.001 and p=0.03). STE longitudinal strain correlated strongly with corresponding CMR-FT longitudinal strain (GLS, GLS and GLS: r=0.81; r=0.82; r=0.81) despite poor intermodal agreement (bias±limits of agreement (LoA): -2.84±4.06%; 0.16±3.68%; 2.33±3.52%) whereas GCS, GCS and GCS correlated weakly between the two modalities (r=0.28; r=0.19; r=0.34) and displayed poor intermodal agreement (bias±LoA:-1.33±6.86%; 4.43±6.49%; -9.92±8.55%).
Conclusions
STE and CMR-FT longitudinal and circumferential layer-specific strain parameters are preload dependent both in 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 due to poor intermodal agreement.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Jan 2021; epub ahead of print
Grund FF, Kristensen CB, Myhr KA, Vejlstrup N, Hassager C, Mogelvang R
J Am Soc Echocardiogr: 05 Jan 2021; epub ahead of print | PMID: 33421611
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Abstract

The Obesity Paradox in Patients with Significant Tricuspid Regurgitation: Effects of Obesity on Right Ventricular Remodeling and Long-Term Prognosis.

Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V
Background
Obesity may cause right ventricular (RV) remodeling due to volume overload. However, obesity is also associated with better prognosis compared with normal weight in patients with various cardiac diseases. The aim of this study was to assess the impact of obesity on RV remodeling and long-term prognosis in patients with significant (moderate and severe) tricuspid regurgitation (TR).
Methods
A total of 951 patients with significant TR (median age, 70 years; interquartile range, 61-77 years; 50% men) were divided into three groups according to body mass index (BMI): normal weight (BMI 18.5-24.9 kg/m), overweight (BMI 25-29.9 kg/m), and obese (BMI ≥ 30 kg/m). Patients with congenital heart disease, peripheral edema, active endocarditis, and BMI < 18.5 kg/m were excluded. RV size and function for each group were measured using transthoracic echocardiography and compared with reference values of healthy study populations. The primary end point was all-cause mortality. Event rates were compared across the three BMI categories.
Results
Four hundred seventy-six patients (50%) with significant TR had normal weight, 356 (37%) were overweight, and 119 (13%) were obese. RV end-diastolic and end-systolic areas were larger in overweight and obese patients compared with normal-weight patients. However, no differences in RV systolic function were observed. During a median follow-up period of 5 years, 358 patients (38%) died. Five-year survival rates were significantly better in overweight and obese patients compared with patients with normal weight (65% and 67% vs 58%, respectively, P < .001 and P = .005). In multivariate analysis, overweight and obesity were independently associated with lower rates of all-cause mortality compared with normal weight (hazard ratios, 0.628 [95% CI, 0.493-0.800] and 0.573 [95% CI, 0.387-0.848], respectively).
Conclusions
In patients with significant TR, overweight and obese patients demonstrated more RV remodeling compared with patients with normal weight. Nevertheless, a higher BMI was independently associated with better long-term survival, confirming the obesity paradox in this context.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:20-29
Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V
J Am Soc Echocardiogr: 30 Dec 2020; 34:20-29 | PMID: 32921538
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Abstract

Characteristics and Significance of Tricuspid Valve Prolapse in a Large Multidecade Echocardiographic Study.

Lorinsky MK, Belanger MJ, Shen C, Markson LJ, ... Manning WJ, Strom JB
Background
Characteristics of tricuspid valve prolapse (TVP) on transthoracic echocardiography are not well defined. As tricuspid valve interventions are increasingly considered, information on the definition and clinical significance of TVP is needed.
Methods
At the authors\' institution, between January 26, 2000, and September 20, 2018, 410 patients (0.3%) were determined to have suspected TVP. These transthoracic echocardiograms and those of 97 age- and sex-matched normal control subjects were reviewed. Interrater agreement on TVP by visual inspection was assessed in a blinded subset. Leaflet atrial displacement (AD) > 2 SDs above the mean in normal control subjects was used to identify an empiric definition of TVP Features of patients meeting this definition were evaluated.
Results
Three hundred twelve transthoracic echocardiograms with available and interpretable images (76.1%) were included. Interrater agreement on TVP diagnosis by visual inspection was moderate. Normal values of AD were up to 4 mm in the right ventricular inflow view and 2 mm in all other views. AD > 2 mm in the parasternal short-axis view had the best accuracy against suspected TVP to identify TVP. Those with TVP by this definition more frequently had 3 to 4+ tricuspid regurgitation (22.2% vs 3.1%; P < .001), mitral valve prolapse (MVP; 75.0% vs 3.1%; P < .001), and more clinically significant MVP (greater prevalence of 3 to 4+ mitral regurgitation). No difference in mortality was observed in those with isolated TVP versus TVP and MVP (log-rank P = .93).
Conclusions
In the largest study of TVP to date, interrater agreement on TVP diagnosis by visual inspection was moderate. A cutoff of >2-mm AD in the parasternal short-axis view was optimal to define TVP. Those with TVP by this definition had more significant tricuspid regurgitation, larger right ventricles, and more clinically significant MVP. Overall, these results suggest an increased role for surveillance for TVP and the need for clear diagnostic criteria in updated guidelines.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:30-37
Lorinsky MK, Belanger MJ, Shen C, Markson LJ, ... Manning WJ, Strom JB
J Am Soc Echocardiogr: 30 Dec 2020; 34:30-37 | PMID: 33071045
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Abstract

Natural Course of Nonsevere Secondary Tricuspid Regurgitation.

Spinka G, Bartko PE, Heitzinger G, Prausmüller S, ... Hülsmann M, Goliasch G
Background
Secondary tricuspid regurgitation (sTR) is frequent in patients with heart failure with reduced ejection fraction and is associated with adverse outcomes despite guideline-directed therapy. However, little is known about the natural course of nonsevere sTR and its relation to cardiac remodeling and outcomes. The aims of this study were therefore to investigate the natural course of sTR progression using quantitative measurements, to assess the prognostic impact on long-term mortality, and to identify risk factors associated with progressive sTR.
Methods
A total of 216 patients with heart failure with reduced ejection fraction receiving guideline-directed therapy were included in this long-term observational study. Progression of sTR was quantitatively defined as an increase of 0.2 cm in effective regurgitant orifice area or 15 mL in regurgitant volume, with transition to at least moderate sTR. Kaplan-Meier and Cox regression analyses were applied to assess survival during a 5-year follow-up period.
Results
Among patients with nonsevere sTR at baseline, 62 (29%) experienced sTR progression. Progressive sTR was accompanied by larger left and right atrial volumes (P = .02 and P < .02, respectively) and a higher prevalence of atrial fibrillation (P < .04). During a median follow-up period of 60 months (interquartile range, 37-60 months), 82 patients died. Progression of sTR conveyed a higher risk for long-term mortality (hazard ratio, 1.77; 95% CI, 1.1-2.83; P < .02), even after multivariate adjustment for bootstrap-selected (adjusted hazard ratio, 1.70; 95% CI, 1.06-2.74; P < .03) and clinical confounder (adjusted hazard ratio, 1.80; 95% CI, 1.07-3.05; P < .03) models.
Conclusions
The incidence of progressive sTR despite guideline-directed therapy is associated with adverse cardiac and valvular remodeling as well as a significantly higher long-term mortality. Biatrial enlargement as well as atrial fibrillation are associated with the development of subsequent progressive sTR and may help identify patients at risk for sTR progression, potentially creating a window of opportunity for closer follow-up and newly arising minimally invasive transcatheter repair therapies.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:13-19
Spinka G, Bartko PE, Heitzinger G, Prausmüller S, ... Hülsmann M, Goliasch G
J Am Soc Echocardiogr: 30 Dec 2020; 34:13-19 | PMID: 33036820
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Abstract

The Prognostic Value of Exercise Echocardiography After Percutaneous Coronary Intervention.

Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
Background
Exercise echocardiography (EE) is a valuable noninvasive method for diagnostic and prognostic assessment of ischemic cardiac disease. The prognostic value of a negative EE test is well known overall, but its role in patients who undergo percutaneous coronary intervention remains poorly validated. The aim of this study was to ascertain the prognostic value of treadmill EE and to determine predictors of cardiac events in this population, with an emphasis on nonpositive (negative or inconclusive) test results.
Methods
A retrospective single-center study was performed. It included 516 patients (83% man; mean age, 62 ± 9 years) previously subjected to percutaneous coronary intervention who underwent treadmill EE between 2008 and 2017. Demographic, clinical, echocardiographic, and angiographic data were collected. The occurrence of cardiac events (cardiac death, acute coronary syndrome, or coronary revascularization) during follow-up was investigated. A multivariate Cox regression analysis was used to evaluate predictors of cardiac events. The Kaplan-Meier method was used to evaluate event-free survival rates.
Results
The results of EE were negative for myocardial ischemia in 245 patients (47.5%), inconclusive in 144 (27.9%), and positive in 127 (24.6%). During a mean follow-up period of 40 ± 34 months, cardiac events occurred in 152 patients (29.5%). The positive and negative predictive values of EE were 81.6% and 85.3%, respectively. The sensitivity of the exercise test was 73.9%, with specificity of 90.1%. Predictors of cardiac events were typical angina (hazard ratio [HR], 1.95; 95% CI, 1.16-3.27; P = .011), a positive ischemic response detected by electrocardiographic monitoring during EE (HR, 2.01; 95% CI, 1.21-3.34; P = .007), and the test result (inconclusive result: HR, 1.06; 95% CI, 0.51-2.19; P = .878; positive result: HR, 4.35; 95% CI, 2.42-7.80; P < .001). Patients with inconclusive (log-rank P = .038) and positive (log-rank P < .001) results had significantly more cardiac events during follow-up than those with negative EE test results. Focusing on those patients with nonpositive results, cardiac event-free survival rates at 1, 3, and 5 years were 96.6 ± 0.9%, 88.3 ± 1.9%, and 79.5 ± 2.6%, respectively. In this subpopulation, an inconclusive test result (HR, 1.67; 95% CI, 1.03-2.70; P = .039), more extensive coronary artery disease (two vessels: HR, 1.37; 95% CI, 0.75-2.30; P = .304; three vessels: HR, 2.59; 95% CI, 1.38-4.87; P = .003), and arterial hypertension (HR, 2.07; 95% CI, 1.10-3.91; P = .025) were significantly associated with the occurrence of cardiac events.
Conclusion
Patients with known coronary disease with negative results on EE are at low risk for hard events. Patients with inconclusive results are at higher risk for cardiac events than those with negative results. The detection of patients with low-risk results on EE should decrease the number of unnecessary repeat invasive coronary angiographic examinations.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:51-61
Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
J Am Soc Echocardiogr: 30 Dec 2020; 34:51-61 | PMID: 33036819
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Abstract

Cardiac Reserve and Exercise Capacity: Insights from Combined Cardiopulmonary and Exercise Echocardiography Stress Testing.

Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
Background
Cardiopulmonary exercise testing (CPET) represents the gold standard to estimate peak oxygen consumption (VO) noninvasively. To improve the analysis of the mechanisms behind effort intolerance, we examined whether exercise stress echocardiography measurements relate to directly measured peak VO during exercise in a large cohort of patients within the heart failure (HF) spectrum.
Methods
We performed a symptom-limited graded ramp bicycle CPET exercise stress echocardiography in 30 healthy controls and 357 patients: 113 at risk of developing HF (American College of Cardiology/American Heart Association stage A-B) and 244 in HF stage C with preserved (HFpEF, n = 101) or reduced ejection fraction (HFrEF, n = 143).
Results
Peak VO significantly decreased from controls (23, 21.7-29.7 mL/kg/minute; median, interquartile range) to stage A-B (18, 15.4-20.7 mL/kg/minute) and stage C (HFpEF: 13.6, 11.8-16.8 mL/kg/minute; HFrEF: 14.2, 10.7-17.5 mL/kg/minute). A regression model to predict peak VO revealed that peak left ventricular (LV) systolic annulus tissue velocity (S\'), peak tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (right ventricle-pulmonary artery coupling), and low-load left atrial (LA) reservoir strain/E/e\' (LA compliance) were independent predictors, in addition to peak heart rate, stroke volume, and workload (adjusted R = 0.76, P < .0001). The model was successfully tested in subjects with atrial fibrillation (n = 49) and with (n = 224) and without (n = 163) beta-blockers (all P < .01). Peak S\' showed the highest accuracy in predicting peak VO < 10 mL/kg/minute (cut point ≤ 7.5 cm/sec, area under the curve = 0.92, P < .0001) and peak VO > 20 mL/kg/minute (cut point > 12.5 cm/sec, area under the curve = 0.84, P < .0001) in comparison with the other cardiac variables of the model (P < .05).
Conclusions
Peak VO is directly related to measures of LV systolic function, LA compliance, and right ventricle-pulmonary artery coupling, in addition to heart rate and stroke volume and independently of workload, age, and sex. The evaluation of cardiac mechanics may provide more insights into the causes of effort intolerance in subjects from HF stages A-C.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:38-50
Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
J Am Soc Echocardiogr: 30 Dec 2020; 34:38-50 | PMID: 33036818
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Impact:
Abstract

Effect of Regional Upper Septal Hypertrophy on Echocardiographic Assessment of Left Ventricular Mass and Remodeling in Aortic Stenosis.

Guzzetti E, Tastet L, Annabi MS, Capoulade R, ... Clavel MA, Pibarot P
Background
Transthoracic echocardiography (TTE) is the reference method for evaluation of aortic stenosis (AS), and it is extensively used to quantitate left ventricular (LV) mass and volumes. Regional upper septal hypertrophy (USH) or septal bulge is a frequent finding in patients with AS and may lead to overestimation of LV mass when using linear measurements. The objective of this study was to compare estimates of LV mass obtained by two-dimensional transthoracic echocardiographic LV dimensions measured at different levels of the LV cavity with those obtained by cardiovascular magnetic resonance (CMR).
Methods
One hundred six patients (mean age, 63 ± 15 years; 68% men) with AS were included in this subanalysis of the PROGRESSA study. Two-dimensional transthoracic echocardiographic measurements of LV dimensions were obtained at the basal level (BL; as recommended in guidelines), immediately below the septal bulge (BSB), and at a midventricular level (ML). Regional USH was defined as a basal interventricular septal thickness ≥ 13 mm and >1.3 times the thickness of the septal wall at the ML. Agreement between transthoracic echocardiographic and CMR measures was evaluated using Bland-Altman analysis.
Results
The distribution of AS severity was mild in 23%, moderate in 57%, and severe in 20% of patients. Regional USH was present in 28 patients (26%). In the whole cohort, two-dimensional TTE overestimated LV mass (bias: BL, +60 ± 31 g; BSB, +59 ± 32 g; ML, +54 ± 32 g; P = .02). The biplane Simpson method slightly but significantly underestimated LV end-diastolic volume (bias -10 ± 20 mL, P < .001) compared with CMR. Overestimation of LV mass was more marked in patients with USH when measuring at the BL and was significantly lower when measuring LV dimensions at the ML (P < .025 vs BL and BSB).
Conclusions
Two-dimensional TTE systematically overestimated LV mass and underestimated LV volumes compared with CMR. However, the bias between TTE and CMR was less important when measuring at the ML. Measurements at the BL as suggested in guidelines should be avoided, and measurements at the ML should be preferred in patients with AS, especially in those with USH.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:62-71
Guzzetti E, Tastet L, Annabi MS, Capoulade R, ... Clavel MA, Pibarot P
J Am Soc Echocardiogr: 30 Dec 2020; 34:62-71 | PMID: 33067075
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Impact:
Abstract

Three-Dimensional Imaging and Dynamic Modeling of Systolic Anterior Motion of the Mitral Valve.

Vainrib A, Massera D, Sherrid MV, Swistel DG, ... Williams MR, Saric M

Left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM) is often caused by systolic anterior motion (SAM) of the mitral valve caused by the interplay between increased left ventricular (LV) wall thickness and an abnormal mitral valve anatomy and geometry. Three-dimensional (3D) echocardiographic imaging of the mitral valve has revolutionized the practice of cardiology, paving the way for new methods to see and treat valvular heart disease. Here we present the novel and incremental value of 3D transesophageal echocardiography (TEE) of SAM visualization. This review first provides step-by-step instructions on acquiring and optimizing 3D TEE imaging of SAM. It then describes the unique and novel findings using standard 3D TEE rendering as well as dynamic mitral valve modeling of SAM from 3D data sets, which can provide a more detailed visualization of SAM features. The findings include double-orifice LVOT caused by the residual leaflet, the dolphin smile phenomenon, and delineation of SAM width. Finally, the review discusses the essential role of 3D TEE imaging for preprocedural assessment and intraprocedural guidance of surgical and novel percutaneous treatments of SAM.

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

J Am Soc Echocardiogr: 30 Dec 2020; 34:89-96
Vainrib A, Massera D, Sherrid MV, Swistel DG, ... Williams MR, Saric M
J Am Soc Echocardiogr: 30 Dec 2020; 34:89-96 | PMID: 33059963
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Impact:
Abstract

Markers of Elevated Left Ventricular Filling Pressure are Associated with Increased Mortality in Non-Severe Aortic Stenosis.

Giudicatti LC, Burrows BMath S, Playford D, Strange G, Hillis BMedBiol G
Background
Echocardiographic measures of elevated left ventricular filling pressures are associated with an adverse prognosis. The aim of this study was to determine the relationship between acute (ratio of early transmitral flow to mitral annular velocities; E/e\') and chronic (indexed left atrial volume; LAVI) markers of left ventricular filling pressure (LVFP) and mortality in patients with non-severe aortic stenosis (AS), within the National Echo Database of Australia cohort. We hypothesised that they would reflect the early haemodynamic consequences of AS and be associated with increased mortality in this setting.
Methods
The first record for patients 18 years or over showing hemodynamically significant but non-severe (mild or moderate) AS (mean pressure gradient ≥10 to <40mmHg and AVA>1cm) was analysed. Baseline demographics and echocardiographic variables were compared to patients without AS (mean pressure gradient <10mmHg). Mortality linkage data were available for all patients.
Results
Of 78,886 patients with aortic valve mean pressure gradient <40mmHg and AVA>1cm, 13,768 (17%) were identified with non-severe AS (aortic valve mean pressure gradient 10-40mmHg), of which 57% were male (mean age 73 ±13.4 years) with a median follow-up of 3.4 years (interquartile range: 1.7-6.1 years). In unadjusted time varying coefficient models, non-severe AS and a LAVI>34ml/m [Hazard Ratio (HR)=2.29 (95% CI 2.03-2.58)], an E/e\'>14 [HR=2.27 (95% CI 2.08-2.49)], a left ventricular ejection fraction (LVEF) <50% [HR 2.82 (95% CI 2.50-3.19)], and a tricuspid regurgitation (TR) peak velocity>280cm/s [HR=2.54 (95% CI 2.30-2.80)] were associated with increased mortality hazard at the time of the echocardiogram. All markers were significant when combined in a multi-variable model.
Conclusions
Indices of elevated LVFP are independently associated with death in non-severe AS. Risk stratification models incorporating these variables may identify patients at risk of complications, warranting closer surveillance and possibly earlier intervention.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 30 Dec 2020; epub ahead of print
Giudicatti LC, Burrows BMath S, Playford D, Strange G, Hillis BMedBiol G
J Am Soc Echocardiogr: 30 Dec 2020; epub ahead of print | PMID: 33388447
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Abstract

Prognostic value of intraplaque neovascularization detected by carotid Contrast-Enhanced Ultrasound in patients undergoing stress echocardiography.

Huang R, DeMarco JK, Ota H, Macedo TA, ... Pellikka PA, Mulvagh SL
Background
Stress echocardiography (SE) is used for diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). Contrast-enhanced ultrasound (CEUS) detects carotid intraplaque neovascularization (IPN).
Objectives
We hypothesized that combining SE with carotid CEUS in patients with known or suspected CAD may provide incremental prognostic value beyond clinical risk factors and either test alone for the occurrence of cardiovascular events.
Methods
185 patients (69 + 8 years; 79% men) with known or suspected CAD referred for SE and found to have carotid plaque on screening were recruited for carotid CEUS imaging. IPN was graded by presence and location within plaque. Patients were followed for cardiovascular events (CVE) including cardiac death, myocardial infarction, unstable angina, transient ischemic attack /stroke. A subset of patients (n=27) underwent carotid magnetic resonance imaging (MRI) within one month of CEUS; carotid plaque was assessed for lipid-rich necrotic core (LRNC %), loose matrix, and presence of intraplaque hemorrhage (IPH).
Results
Sixty-nine patients had abnormal SE. IPN was identified in 112 patients; 52 patients had IPN localized to plaque shoulder (IPNS). Plaques with IPNS had larger LRNC% and were more likely to have IPH. During follow-up (median 31 months), 26 CVE occurred. Multivariate Cox proportional hazard analysis showed IPN and IPNS to be predictors of CVE [hazard ratio (95% CI): 3.34 (1.25-8.93), P=0.02 and 4.88 (1.77-13.49), p=0.002, respectively]. The presence of IPNS increased the likelihood of CVE beyond SE and history of CAD (χ2=9.0, p=0.02).
Conclusion
Carotid intraplaque neovascularization detected by CEUS and localized to plaque shoulder, was an independent predictor of CVE in patients referred for stress echocardiography.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 29 Dec 2020; epub ahead of print
Huang R, DeMarco JK, Ota H, Macedo TA, ... Pellikka PA, Mulvagh SL
J Am Soc Echocardiogr: 29 Dec 2020; epub ahead of print | PMID: 33387609
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Impact:
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 (CTr) and superior mesenteric artery (SMA) and their evaluation is usually based on computed tomography angiography (CTA). Transesophageal echocardiography (TEE) is also a useful technique for diagnosing AAD and is essential in monitoring surgical or endovascular treatment when CTA is not available. However, the usefulness of TEE for evaluating CTr and SMA 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 the operating room to achieve prompt diagnosis and better therapeutic management. This review aims to assess the role of TEE to diagnose CTr and SMA involvement in AAD, determine the mechanisms which can cause flow obstruction in patients with mesenteric ischemia and analyze possible implications in the treatment of this complication.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 28 Dec 2020; epub ahead of print
Moral S, Avegliano G, Cuéllar H, Ballesteros E, ... Gutiérrez L, Evangelista A
J Am Soc Echocardiogr: 28 Dec 2020; epub ahead of print | PMID: 33385502
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Abstract

Echocardiographic Findings Associated with Transplant-free Survival and Left Ventricular Systolic Function at Mid-term Follow-up after Ross Procedure in Infants with Critical Aortic Stenosis.

Porter A, Yu S, Lowery R, Fifer CG, Lu JC
Background
The Ross operation is an important option for children with critical aortic stenosis (CAS) with residual disease, but operation in infancy is associated with significant morbidity and mortality. We evaluated echocardiographic correlates of transplant-free survival, re-intervention, and left ventricular (LV) function in mid-term follow-up.
Methods
This retrospective, single-center study included all infants with CAS who underwent Ross by 1 year of age from 1/2000 to 9/2018. Serial echocardiograms were analyzed for LV ejection fraction (EF) and systolic and diastolic longitudinal strain (LS). The primary outcome was mortality or transplant; secondary outcomes were re-intervention and abnormal LVEF (≤55%).
Results
In 40 infants (30 [75%] male; median age at Ross 51 days) with median follow-up 3.3 years (interquartile range 1.0-9.4), the primary outcome was met in 11/40 (28%). Transplant-free survival was 79%, 77%, and 69% at 1, 5, and 10 years post Ross. Predictors of transplant or death included neonatal surgery, cross-clamp time, and pre-operative left atrial dilatation and lower LVEF. Median freedom from re-intervention was at 7.1 years post Ross, with no identified associations. LV LS improved 1 year post-Ross (-21.1±3.8% vs. -17.4±5.1%, p=0.02), although LVEF did not reach significance. Lower LVEF at 1 year was related to pre-Ross LA dilatation (p=0.02), abnormal LVEF (p=0.04), and lower early diastolic LS rate (p=0.03). LVEF remained stable 3-years post Ross.
Conclusion
Both transplant-free survival and normalization of LV function post Ross in infancy are associated with pre-operative LV systolic and diastolic measures, highlighting the prognostic value of echocardiography in this population. Further data are necessary in a larger, multicenter cohort, to allow for more precise risk stratification.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 28 Dec 2020; epub ahead of print
Porter A, Yu S, Lowery R, Fifer CG, Lu JC
J Am Soc Echocardiogr: 28 Dec 2020; epub ahead of print | PMID: 33385500
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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 Dec 2020; epub ahead of print
Benfari G, Nistri S, Marin F, Cerrito LF, ... Rossi A, Ribichini FL
J Am Soc Echocardiogr: 27 Dec 2020; epub ahead of print | PMID: 33253813
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Abstract

Asymmetric Regional Work Contributes to Right Ventricular Fibrosis, Inefficiency and Dysfunction in Pulmonary Hypertension versus Regurgitation.

Ebata R, Fujioka T, Diab SG, Pieles G, ... Stortz G, Friedberg MK
Background
Right ventricular (RV) pressure loading from pulmonary hypertension (PH) and volume loading from pulmonary regurgitation (PR) lead to RV dysfunction, a critical determinant of clinical outcomes, but their impact on regional RV mechanics and fibrosis are poorly characterized. Here, we hypothesized that regional myocardial mechanics and efficiency in RV pressure and volume loading are associated with RV fibrosis and dysfunction.
Methods
Eight PH, six PR and five Sham-control rats were studied. The PH rat model was induced using Sugen5416, a vascular endothelial growth factor receptor 2 inhibitor, combined with chronic hypoxia. PR rats were established by surgical laceration of the pulmonary valve leaflets. Six (n=4) or nine weeks (n=4) after Sugen5416/hypoxia and twelve weeks after PR surgery, myocardial strain and RV pressure were measured and RV pressure-strain loops generated. We further studied RV regional mechanics in eleven patients with PH. Regional myocardial work was calculated as the pressure-strain loop area (mmHg∙%). Regional myocardial work efficiency was quantified through wasted work (ratio of systolic lengthening to shortening work). The relation of regional myocardial work to RV fibrosis and dysfunction was analyzed.
Results
In rats, PH and PR induced similar RV dilatation, but fractional area change (%) was lower in PH than in PR. RV lateral wall work was asymmetrically higher in PH compared with Sham, while septal work was similar to Sham. In PR, lateral and septal work were symmetrically higher versus Sham. Myocardial wasted work ratio was asymmetrically increased in the PH septum versus Sham. Fibrosis in the RV lateral wall, but not septum, was higher in PH than PR. RV fibrosis burden was linearly related to regional work and to measures of RV systolic and diastolic function, but not to wasted myocardial work ratio. Patients with PH demonstrated similar asymmetric and inefficient regional myocardial mechanics.
Conclusions
Asymmetric RV work and increased wasted septal work in experimental PH are associated with RV fibrosis and dysfunction. Future investigation should examine whether assessment of asymmetric regional RV work and efficiency can predict clinical RV failure and influence patient management.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 27 Dec 2020; epub ahead of print
Ebata R, Fujioka T, Diab SG, Pieles G, ... Stortz G, Friedberg MK
J Am Soc Echocardiogr: 27 Dec 2020; epub ahead of print | PMID: 33383122
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Impact:
Abstract

Comprehensive Assessment of Right Ventricular Function by Three-Dimensional Speckle-Tracking Echocardiography: Comparisons with Cardiac Magnetic Resonance Imaging.

Li Y, Zhang L, Gao Y, Wan X, ... Shi H, Xie M
Background
Three-dimensional speckle tracking echocardiography (3D-STE) has been increasingly used to quantify right ventricular (RV) function. However, direct comparisons of 3D-STE with cardiac magnetic resonance (CMR) imaging for evaluation of RV function are limited. This study aimed to test the feasibility and accuracy of 3D-STE for the quantification of RV volumes, ejection fraction (EF), and longitudinal strain in comparison with CMR imaging and to determine whether 3D-STE for RV strain is superior to two-dimensional(2D)-STE in comparison with CMR imaging.
Methods
A total of 195 consecutive patients referred for both CMR imaging and echocardiography were studied. RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RVEF, as well as 3D RV free wall longitudinal strain (3D-RVLS) by 3D-STE and 2D-RVLS by 2D-STE, were compared with CMR measurements. Pearson correlation and Bland-Altman analyses were used to assess the inter-technique agreement.
Results
RV 3D-STE was feasible in 174 patients (89%). RV volumes and EF determined by 3D-STE strongly correlated with CMR values (RVEDV, r = 0.94; RVESV, r = 0.96; RVEF, r = 0.91; all P < .001). 3D-STE slightly underestimated the RV volumes and longitudinal strain, and overestimated the RVEF. The 3D-RVLS values correlated better than 2D-RVLS values with CMR values (0.85 vs 0.64, P < .001) with smaller bias and narrower limits of agreement (bias: 2.0 and 2.6; limits of agreement: 8.5 and 12.5, respectively). The bias and limits of agreement for 3D-STE-obtained RVLS were increased in patients with RV dilation, RVEF < 45% or lower frame rate compared to those with normal RV size, RVEF ≥45% or higher frame rate, respectively. RV 3D-STE measurements were highly reproducible.
Conclusions
The 3D-STE measurements of RV volumes, EF and longitudinal strain are highly feasible and reproducible, and data measured by 3D-STE correlate strongly with those determined using CMR imaging. Thus, 3D-STE may be a valid alternative to CMR imaging for the quantification of RV function in everyday clinical practice.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 27 Dec 2020; epub ahead of print
Li Y, Zhang L, Gao Y, Wan X, ... Shi H, Xie M
J Am Soc Echocardiogr: 27 Dec 2020; epub ahead of print | PMID: 33383121
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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 T
Background
Intermittent high mechanical index (MI) impulses from a transthoracic ultrasound transducer are recommended for regional wall motion (RWM) analysis and assessment of myocardial perfusion following an 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 via a purinergic signaling pathway, but their effects on left ventricular (LV) myocardial function are unknown. Therefore, we investigated the effect of transthoracic intermittent high MI (IH MI) impulses during an intravenous UEA infusion in patients with normal and abnormal resting systolic function.
Methods
Fifty patients referred for echocardiography to evaluate LV systolic function during a continuous infusion of UEAs (Definity 3% infusion), were prospectively assigned to: Group 1: low MI (<0.2) imaging alone; or Group 2: low MI (<0.2) imaging with IH MI impulses (five frames; 1.8 MHz, 1.0-1.1 MI) applied at least two times in each apical window to clear myocardial contrast. Global (GLS) strain measurements were obtained at baseline prior to UEA administration and at five minute intervals up to 10 minutes after infusion completion.
Results
There were no differences between groups with respect to age, gender, resting GLS, biplane left ventricular ejection fraction (LVEF), or cardiac risk factors. Resting GLS in group 1 was -15.5 + 5.2% before to -15.5 + 5.4% at 10 minutes after UEA infusion. In comparison, GLS increased in Group II (-15.3+5.0 before and -16.8 + 4.8 % at 10 minutes; p<0.00001). Improvements in GLS were seen in patients with normal and abnormal systolic function. Regional analysis demonstrated the increase in strain in the abnormal LVEF patients was primarily in the apical segments (-12.0+2.7% before to -13.4+3.4% at 10 minutes after IH MI; p=0.001).
Conclusions
High mechanical index impulses during a commercially available contrast infusion can improve left ventricular systolic function, and may have therapeutic effect in patients with left ventricular dysfunction.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Dec 2020; epub ahead of print
Albulushi A, Olson J, Xie F, Qian L, ... Aboeata A, Porter T
J Am Soc Echocardiogr: 26 Dec 2020; epub ahead of print | 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 (LV) enlarges significantly or develops systolic dysfunction (EF <50%). Valve guidelines recommend aortic valve repair or replacement (AVR) for LV linear end-systolic dimension (LVESD) ≥ 50 mm or end-diastolic dimension ≥ 65 mm. However, chamber quantification guidelines recommend using LV volume for LV size determination as linear measurements may not accurately reflect LV remodeling. We sought to evaluate the correlation of LV volumes with linear dimensions, inter-observer variability in estimation of volumes, and association of volumes with outcomes in patients with AR.
Methods
We retrospectively analyzed 1100 consecutive patients with chronic moderate-severe and severe AR by echocardiography between 2004 and 2019. Modified Simpson\'s disc summation method was used for LV volume estimation. The primary outcome was all-cause mortality; secondary outcome was mortality censored at AVR.
Results
Patients\' age was 60 ± 17 years and 198 (18%) were women. Volumes were measured by biplane method in 939 (85%) patients and monoplane in 161 (15%); end-systolic volume was normal in 169 (11%). Correlations between volumes and linear dimensions were 0.5 for end-diastolic and 0.6 for end-systolic. At median follow up of 5.4 (2.4-10.0) years, 216 patients died and 539 underwent AVR. Indexed LV end-systolic volume (iLVESV) and iLVESD were both associated with mortality and symptoms, but association of iLVESV was stronger. iLVESV, age, male gender, Charlson comorbidity index, NYHA class III-IV, and time dependent AVR were independently associated with all-cause mortality. The inter-observer variability in estimation of LV volumes in 200 patients included intra-class coefficient 0.94 (0.92-0.95) for end-diastolic and 0.88 (0.78-0.93) for end-systolic volume. Patients with iLVESV≥45ml/m had lower survival and higher prevalence of symptoms than those with volumes <45 ml/m.
Conclusion
Echocardiographic LV volume assessment had good reproducibility in patients with moderate-severe and severe AR. The correlation between linear dimensions and volumes was limited. Both iLVESV and iLVESD were associated with worse outcomes, but association of iLVESV was stronger. iLVESV ≥45ml/m was associated with worse outcomes.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Dec 2020; epub ahead of print
Anand V, Yang L, Luis SA, Padang R, ... Nishimura RA, Pellikka PA
J Am Soc Echocardiogr: 26 Dec 2020; epub ahead of print | PMID: 33253815
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Impact:
Abstract

Tricuspid regurgitation in Hypoplastic Left Heart Syndrome: Three-dimensional echocardiography provides additional information in describing jet location.

Mah K, Khoo NS, Tham E, Yaskina M, ... Smallhorn J, Colen T
Background
Twenty-five percent of hypoplastic left heart syndrome (HLHS) patients require tricuspid valve (TV) repair. Location of tricuspid regurgitation (TR) is important in determining the type of repair performed. Three-dimensional echocardiography (3DE) studies report a high incidence of error in 2DE identification of TV leaflets. This study compares 3DE and 2DE assessment of TR in HLHS (jet location, TR grade, reproducibility).
Methods
We performed a retrospective, single center review. Fifty-six HLHS patients with available 2DEs and 3DEs, and mild or greater TR, were included. TR location, grade, vena contracta (VC) area, and TV annulus diameter were measured from 2DE and 3DE. Reproducibility was assessed by blinded reviewers.
Results
3DE identified primary jet location as central (57%), followed by antero-septal (36%). There was poor agreement between 3DE and 2DE findings for jet location (kappa 0.05; CI: -0.08 to 0.19). Interobserver reproducibility for 3DE location was excellent (kappa 0.8), whereas 2DE reproducibility was poor (kappa 0.32). The most common jet location pre-Norwood and pre-Glenn is central (70%); whereas pre-Fontan and post-Fontan the location is central (45%) and anterior-septal (48%). 2DE VC area correlated moderately with 3DE VC area (r = 0.60, p<0.0001). 2DE and 3DE TV annulus diameter for lateral (r = 0.85, p<0.0001) and anterior-posterior (r= 0.74, p= 0.001) dimensions were strongly correlated.
Conclusions
In children with HLHS, 2DE assessment of TR location has poor agreement with 3DE and was poorly reproducible. In contrast, 3DE TR jet location was highly reproducible. Pre-Glenn, a central TR jet was the most common, while post-Glenn central and anteroseptal locations were equal, highlighting the importance of pre-operative identification of TR jet location in HLHS patients.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 25 Dec 2020; epub ahead of print
Mah K, Khoo NS, Tham E, Yaskina M, ... Smallhorn J, Colen T
J Am Soc Echocardiogr: 25 Dec 2020; epub ahead of print | PMID: 33373699
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Impact:
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: 23 Dec 2020; epub ahead of print
Zada M, Lo Q, Boyd AC, Bradley S, ... Tchan MC, Thomas L
J Am Soc Echocardiogr: 23 Dec 2020; epub ahead of print | PMID: 33242609
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Impact:
Abstract

Feasibility of Real-Time Myocardial Contrast Echocardiography to Detect Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients.

Fine NM, Greenway SC, Mulvagh SL, Huang R, ... Anderson JH, Johnson JN
Background
Cardiac allograft vasculopathy (CAV) is an important adverse prognostic factor for pediatric heart transplant (HT) recipients. Invasive coronary angiography (ICA) is the gold standard for CAV detection but lacks sensitivity for early microvascular changes and cumulative radiation exposure is of concern. Real-time myocardial contrast echocardiography (RTMCE) using ultrasound enhancing (contrast) agents performed during dobutamine stress echocardiography (DSE) can assess myocardial function, perfusion, and microvascular integrity. The objective of this study was to determine the safety and feasibility of RTMCE during DSE to detect CAV in a pediatric HT population.
Methods
HT patients 10-21 years of age were recruited to undergo DSE with RTMCE to determine technical feasibility, test tolerability and adverse event rate, and detection of perfusion defects compared with ICA detected CAV. Thirty-six patients from two centers were enrolled, mean age 13.5±4.3 years, 21 (58%) were male. Wall motion and myocardial perfusion were qualitatively assessed and compared with ICA findings of CAV. Myocardial blood flow (MBF) at rest and peak stress was quantified, and myocardial blood flow reserve (MBFR) was defined as the ratio of peak to rest MBF.
Results
Five (14%) patients had CAV by ICA, two with obstructive disease and three with mild CAV. RTMCE was feasible in 32 (89%) patients. Three patients had wall motion defects, including one with a mixed defect and two with fixed defects. A perfusion abnormality was present in 5 patients, two of whom had obstructive CAV and one with mild CAV. Sensitivity and specificity of RTMCE for CAV detection was 60% and 94%, respectively, and diagnostic accuracy was 89%. MBFR was feasible in 20 (63%) patients. The mean MBFR was 3.4±0.7. Patients with CAV had lower MBFR than those without (2.0±0.2 versus 3.7±0.8, p<0.01). There were no serious adverse events related to RTMCE.
Conclusion
Dobutamine stress RTMCE appears to be safe and feasible for the assessment of CAV in pediatric HT recipients. Further assessment is warranted to determine if this noninvasive technique could provide a reliable alternative to ICA.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Dec 2020; epub ahead of print
Fine NM, Greenway SC, Mulvagh SL, Huang R, ... Anderson JH, Johnson JN
J Am Soc Echocardiogr: 23 Dec 2020; epub ahead of print | PMID: 33359634
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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, non-invasive identification of heart failure with preserved ejection fraction (HFpEF) patients with congestion may allow for timely tailoring of decongestive therapies. The 2016 American Society of Echocardiography / European Association of Cardiovascular Imaging guidelines provide an algorithm to assess for elevated left atrial pressure (LAP); the associations of echocardiographic LAP (echo-LAP) with clinical status and disease progression in HFpEF are unclear.
Methods
We categorized participants in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF (RELAX) trial into 1 of 4 pre-specified guideline-based echo-LAP categories: 1) normal, 2) elevated, 3) atrial fibrillation (AF) at the time of echocardiography, or 4) indeterminate. We evaluated the associations of echo-LAP categories with baseline exercise capacity, change in exercise capacity, and change in NT-proBNP over 24 weeks.
Results
Of 216 participants, 199 had mitral inflow Doppler echocardiography for LAP categorization. Participants with elevated echo-LAP (n=81) or AF (n=57) were older and had higher prevalence of kidney dysfunction. Compared with the normal echo-LAP group (n=28), elevated echo-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-coefficient for elevated echo-LAP: -1.55 [95% CI: -2.59, -0.51], p=0.004; β-coefficient for AF: -1.33 [95% CI: -2.49, -0.17], p=0.03). Indeterminate echo-LAP (n=33) was also independently associated with a reduction in exercise capacity at 24 weeks compared with normal echo-LAP (β-coefficient: -1.35 [95% CI: -2.51, -0.19], p=0.02). Finally, elevated echo-LAP and AF were significantly associated with increases in NT-proBNP over 24 weeks compared with normal echo-LAP.
Conclusions
In chronic HFpEF, elevated echo-LAP and indeterminate echo-LAP, as defined by contemporary guidelines, and AF were each independently associated with a reduction in exercise capacity compared with normal echo-LAP. These findings suggest potential utility of non-invasive LAP assessment in HFpEF for tailoring treatments that decrease congestion.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 20 Dec 2020; epub ahead of print
Rethy L, Borlaug BA, Redfield MM, Oh JK, Shah SJ, Patel RB
J Am Soc Echocardiogr: 20 Dec 2020; epub ahead of print | PMID: 33359021
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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: 19 Dec 2020; epub ahead of print
Rios DR, Martins FF, El-Khuffash A, Weisz DE, Giesinger RE, McNamara PJ
J Am Soc Echocardiogr: 19 Dec 2020; epub ahead of print | PMID: 33227390
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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: 18 Dec 2020; epub ahead of print
Gan GCH, Kadappu KK, Bhat A, Fernandez F, ... Eshoo S, Thomas L
J Am Soc Echocardiogr: 18 Dec 2020; epub ahead of print | PMID: 33223356
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Abstract

Exercise-induced cardiac fatigue after a 45-minute 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 (EICF), which affects the right ventricle (RV) and to a lesser extent the left ventricle (LV). Hypoxic exposure induces an additional increase in RV afterload. Therefore, exercise in hypoxia may differently affect both ventricles.
Aim
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
21 healthy individuals (22.2±3.0 years, fourteen men) performed a 45-minute high-intensity running exercise, under hypoxia (fraction of inspired oxygen [FiO] 14.5%) and normoxia (FiO 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 LV cardiac function and mechanics. RV structure, function and mechanics were assessed using conventional 2D, Doppler, tissue Doppler, speckle tracking echocardiography and novel strain-area loops.
Results
Indices for RV systolic function (RVFAC, TAPSE, RVS\', RV free wall strain) as well as LV function (LV ejection fraction, LV global longitudinal strain)) significantly reduced after high-intensity running exercise (p<0.01). These exercise-induced changes were more pronounced when echocardiography was examined during stress compared to baseline. These responses in RV or LV were not altered under hypoxia (p>0.05).
Conclusion
There was no impact of hypoxia on the magnitude of EICF in the RV and LV after a bout of 45-minute high-intensity exercise. This finding suggests that any potential increase in loading conditions does not automatically exacerbate EICF in this setting.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 13 Dec 2020; epub ahead of print
Kleinnibbelink G, van Dijk APJ, Fornasiero A, Speretta GF, ... Thijssen DHJ, Oxborough DL
J Am Soc Echocardiogr: 13 Dec 2020; epub ahead of print | PMID: 33333146
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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-extracorporeal membrane oxygenation (VA-ECMO). We sought to determine if echocardiographic parameters during ECMO flow study could predict successful weaning from ECMO.
Methods
A total of 92 ECMO patients from a multi-center 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 successful and failed weaning group.
Results
Sixty-four patients 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 successful weaning group, while such findings were not observed in 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 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 model with conventional echocardiographic predictors from previous studies (LV ejection fraction > 20-25%, LV time-velocity integral ≥ 10cm, mitral annulus S\' ≥ 6cm/s).
Conclusions
Improvement of lateral e\' velocity and tricuspid annular S\' velocity during VA-ECMO flow study may better represent cardiac reserve from 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. Published by Elsevier Inc.

J Am Soc Echocardiogr: 11 Dec 2020; epub ahead of print
Kim D, Jang WJ, Park TK, Cho YH, ... Jeon ES, Yang JH
J Am Soc Echocardiogr: 11 Dec 2020; epub ahead of print | PMID: 33321165
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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: 04 Dec 2020; epub ahead of print
Kawakami H, Wright L, Nolan M, Potter EL, Yang H, Marwick TH
J Am Soc Echocardiogr: 04 Dec 2020; epub ahead of print | PMID: 33293202
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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, Cheng L, Wang J, ... Zhang L, 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 (LVEF) by three-dimensional speckle-tracking echocardiography (3D-STE). The secondary aim was to identify the effect of management strategies on LV remodeling in severe CAR.
Methods
135 subjects and 41 controls were enrolled, the subjects were divided according to regurgitation degree: mild (n = 48), moderate (n = 40), severe (n = 47). A routine follow-up was not possible in 13 patients for the severe CAR group, the remaining 34 patients were divided into three groups based on treatment: surgical (n = 13), drug (n = 11), and untreated (n = 10), and followed for 2.1 ± 0.37 years. All subjects underwent 3D-STE at baseline and follow-up, while 20 patients with CAR also underwent baseline two-dimensional speckle tracking echocardiography (2D-STE) and feature-tracking cardiovascular magnetic resonance imaging (CMR-FT). Volumetric and strain parameters were acquired.
Results
Compared with the global circumferential strain (GCS) derived from 2D-STE and CMR-FT, the 3D GCS was the largest (P < 0.001); however, no significant differences in the 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 < 0.05). During follow-up, LV volumetric indexes and sphericity indexes increased, while GLS, apical rotation, and twist worsened (P < 0.05) in the untreated group. In the surgical group, LV volumetric and sphericity indexes decreased, while GLS and GRS improved (P < 0.05). In the drug group, LV volumetric indexes increased, while LVEF, GLS, and GRS worsened (P < 0.05).
Conclusions
3D-STE may be a reliable tool to monitor progression of ventricular remodeling in CAR. Drug therapy may not prevent progressive ventricular dilatation and myocardial depression.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 01 Dec 2020; epub ahead of print
Zeng Q, Wang S, Cheng L, Wang J, ... Zhang L, Xie M
J Am Soc Echocardiogr: 01 Dec 2020; epub ahead of print | PMID: 33278525
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Abstract

Impact of Appropriate Use Criteria for Transthoracic Echocardiography in Valvular Heart Disease on Clinical Outcomes.

Amadio JM, Bouck Z, Sivaswamy A, Chu C, ... Weiner RB, Bhatia RS
Background
The association between appropriate use criteria for transthoracic echocardiography (TTE) and clinical outcomes is unknown for patients with valvular heart disease (VHD). The aim of this study was to identify the association of TTE appropriateness with downstream cardiac tests and clinical outcomes in patients with VHD over 365 days.
Methods
A subset of 2,297 patients with VHD across six Ontario academic hospitals was selected from the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) trial and linked to administrative databases. Each patient\'s index TTE was classified as \"rarely appropriate\" (rA) versus \"appropriate\" (comprising \"appropriate\" and \"may be appropriate\" TTE according to the 2011 appropriate use criteria). Overall, 431 of 452 patients with rA TTE were matched 1:1 with patients with appropriate TTE using propensity scores to account for measured confounding.
Results
Matched patients with rA TTE were less likely to undergo repeat TTE (relative risk, 0.46; 95% CI, 0.33-0.66) or cardiac catheterization (relative risk, 0.27; 95% CI, 0.16-0.47) at 90 days compared with patients with appropriate TTE. rA TTE was significantly associated with a decreased hazard of aortic valve intervention (hazard ratio, 0.40; 95% CI, 0.14-0.42), all-cause hospitalization (hazard ratio, 0.44; 95% CI, 0.34-0.57), and death (hazard ratio, 0.31; 95% CI, 0.15-0.66) over 365 days of follow-up.
Conclusions
Patients with appropriate TTE for VHD were more likely to undergo subsequent cardiac testing within 90 days and valve intervention within 1 year than those with a rA TTE. The 2011 appropriate use criteria for TTE have important clinical implications for outcomes in patient with VHD.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1481-1489
Amadio JM, Bouck Z, Sivaswamy A, Chu C, ... Weiner RB, Bhatia RS
J Am Soc Echocardiogr: 29 Nov 2020; 33:1481-1489 | PMID: 32893052
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Impact:
Abstract

Identification of Need for Ultrasound Enhancing Agent Study (the IN-USE Study).

Fraiche AM, Manning WJ, Nagueh SF, Main ML, Markson LJ, Strom JB
Background
Ultrasound enhancing agents (UEAs) are routinely used to improve transthoracic echocardiographic (TTE) image quality, yet anticipation of UEA need is a barrier to their use.
Methods
Structured report data from 171,509 consecutive TTE studies in 97,515 patients who underwent TTE imaging from January 26, 2000, to September 20, 2018, were analyzed. Trends in UEA use and suboptimal image quality were examined. Among outpatients (92,291 TTE examinations, n = 56,479), the data set was randomly split into a 75% derivation sample and a 25% validation sample. Logistic regression was used to model the composite of either UEA receipt or suboptimal image quality (two or more nonvisualized segments) using only variables available at the start of the TTE examination. Model performance was tested in the validation sample.
Results
A total of 4,444 TTE examinations (2.6%) in 3,827 patients (3.9%) involved UEAs, and 28,468 TTE examinations (16.6%) in 21,994 patients (22.5%) were suboptimal. UEA use increased over the observation period. Among TTE studies with suboptimal image quality, UEA use was lower in women (P < .0001). Among outpatients referred for TTE imaging, older age, greater weight, and higher heart rate best predicted UEA use or suboptimal image quality. Model performance in the validation sample was excellent (C statistic = 0.74 [95% CI, 0.73-0.75]; calibration slope = 1.11 [95% CI, 1.06-1.15]).
Conclusions
In this large, single-center, retrospective study, UEA use remained substantially below rates of suboptimal image quality, despite increases over time. Among outpatients, a simple prediction rule using three routinely collected variables available before TTE image acquisition predicted potential benefit from UEAs with high accuracy. If confirmed in other cohorts, this rule may be used to identify patients who may benefit from intravenous placement for UEA administration before TTE image acquisition, thus potentially improving work-flow efficiency.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1500-1508
Fraiche AM, Manning WJ, Nagueh SF, Main ML, Markson LJ, Strom JB
J Am Soc Echocardiogr: 29 Nov 2020; 33:1500-1508 | PMID: 32919859
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Impact:
Abstract

Prognostic Importance of Left Ventricular Global Longitudinal Strain in Patients with Severe Aortic Stenosis and Preserved Ejection Fraction.

Thellier N, Altes A, Appert L, Binda C, ... Tribouilloy C, Maréchaux S
Background
Impaired left ventricular (LV) speckle-tracking-derived global longitudinal strain (GLS) magnitude (GLS worse than 14.7%) has been associated with poor outcome in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (EF).
Objectives
To test the hypothesis that GLS magnitude ≤ 15% obtained with vendor-independent speckle-tracking strain software may be able to identify patients with severe AS who are at higher risk of death, despite preserved LVEF and no or mild symptoms.
Methods
GLS was retrospectively obtained in 332 patients with severe AS (aortic valve area indexed [AVAi] < 0.6 cm/m), no or mild symptoms, and LVEF ≥ 50%. Absolute values of GLS were collected. Survival analyses were carried out to study the impact of GLS magnitude on all-cause mortality.
Results
During a median follow-up period of 42 (37-46) months, 105 patients died. On multivariate analysis, and after adjustment of known clinical and/or echocardiographic predictors of outcome and aortic valve replacement as a time-dependent covariate, GLS magnitude ≤ 15% was independently associated with mortality during follow-up (all P < .01). Adding GLS magnitude ≤ 15% (adjusted hazard ratio = 1.99 [1.17-3.38], P = .011) to a multivariate model including clinical and echocardiographic variables of prognostic importance (aortic valve replacement, aortic valve area, LV stroke volume index < 30 mL/m, and LVEF<60%) improved the predictive performance with improved global model fit, reclassification, and better discrimination. After propensity score matching (n = 196), increased risk of mortality persisted among patients with GLS magnitude ≤ 15% compared with those with GLS > 15% (hazard ratio = 2.10; 95% confidence interval, 1.20-3.68; P = .009).
Conclusions
In this series of patients with severe AS, no or mild symptoms, and LVEF ≥ 50%, GLS obtained with vendor-independent speckle-tracking strain software was an effective tool to identify patients with a poor outcome. Detection of myocardial dysfunction by identifying GLS magnitude < 15% in patients with severe AS, no or mild symptoms, and LVEF ≥ 50%, can aid in risk assessment.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1454-1464
Thellier N, Altes A, Appert L, Binda C, ... Tribouilloy C, Maréchaux S
J Am Soc Echocardiogr: 29 Nov 2020; 33:1454-1464 | PMID: 32919856
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Abstract

Identification of Subclinical Myocardial Dysfunction and Association with Survival after Transcatheter Mitral Valve Repair.

Fukui M, Niikura H, Sorajja P, Hashimoto G, ... Gössl M, Cavalcante JL
Background
Transcatheter mitral valve repair (TMVr) using edge-to-edge mitral valve clip is effective for patients with mitral regurgitation (MR) and high or prohibitive surgical risk. Global longitudinal strain (GLS) allows evaluation of subclinical myocardial dysfunction, but its incremental clinical utility into risk stratification, beyond traditional clinical parameters, is unknown in patients treated with TMVr. We sought to evaluate the association of baseline GLS with 1-year all-cause mortality in patients treated with TMVr using edge-to-edge mitral valve clip.
Methods
We analyzed 155 patients who underwent transcatheter edge-to-edge mitral valve clip implantation (mean age, 83 ± 7 years; 48% were women; mean left ventricular ejection fraction, 56% ± 10%, Society of Thoracic Surgeons Predicted Risk of Mortality score for repair, 6.62% ± 5.22%). Baseline left ventricular GLS was obtained by two-dimensional speckle-tracking echocardiography, averaging 18 segments from three apical views. Receiver operating characteristic analyses were used to assess the GLS cut point associated with all-cause mortality. Multivariable models with Cox regression tested its relationship after adjustment for baseline comorbidities.
Results
During a median follow-up of 316 days, all-cause deaths occurred in 30 patients at a median of 156 days after TMVr. The area under the curve of preoperative GLS associated with the outcome was 0.60, with a cutoff point of -14.5%. Baseline GLS > -14.5% was associated with 1-year mortality (hazard ratio = 2.50; 95% CI, 1.20-5.21; P = .02) before and after adjustment for baseline characteristics. After accounting for baseline characteristics, patients with GLS > -14.5% had worse 1-year mortality than those with GLS ≤ -14.5% (χP < .001). In nested Cox proportional hazards models, the addition of baseline GLS to Society of Thoracic Surgeons Predicted Risk of Mortality score, left ventricular ejection fraction, and the etiology of MR significantly increased the model χ value (χ = 12.32).
Conclusions
Baseline GLS is independently associated with 1-year all-cause mortality in patients who undergo TMVr, and its assessment improves risk stratification in these patients.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1474-1480
Fukui M, Niikura H, Sorajja P, Hashimoto G, ... Gössl M, Cavalcante JL
J Am Soc Echocardiogr: 29 Nov 2020; 33:1474-1480 | PMID: 32919854
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Impact:
Abstract

Prevalence and Prognostic Implications of Increased Apical-to-Basal Strain Ratio in Patients with Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement.

Dahl Pedersen AL, Povlsen JA, Dybro A, Clemmensen TS, ... Ladefoged B, Poulsen SH
Background
The aim of this study was to investigate the preoperative prevalence, relation to symptoms, and prognostic implications of elevated left ventricular (LV) apical-to-basal strain ratio (ABr) in patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement.
Methods
A total of 499 contemporary consecutive patients with AS treated with transcatheter aortic valve replacement were retrospectively included. Patients were included if they underwent preoperative echocardiography with adequate image quality for assessment of LV global longitudinal strain. Baseline clinical and echocardiographic data were collected and analyzed in ABr subgroups. From two-dimensional echocardiographic apical images, ABr was calculated as mean longitudinal strain of the five LV apical segments divided by the mean of the six basal segments.
Results
Median follow-up time was 743 days. Mean age was 79.8 ± 7 years. The prevalence of severely increased ABr ≥4 was 16% (n = 78). Patients with ABr ≥4 had higher preoperative New York Heart Association functional class; 77% of those with ABr ≥4 were in New York Heart Association functional class III or IV compared with 59% of those with ABr of 0 to 1.9 (P < .01). Median preoperative N-terminal pro-brain natriuretic peptide level in patients with ABr ≥4 was 1,781 pmol/L, compared with 876 pmol/L in those with ABr of 0 to 1.9 (P = .003). N-terminal pro-brain natriuretic peptide levels at 3-month follow-up remained considerably elevated in patients with ABr ≥4 (the median in patients with ABr ≥4 was 1,262 pmol/L vs 645 pmol/L in those with ABr of 0 to 1.9, P < .01). AS severity was comparable across ABr subgroup levels. Overall, increased ABr ≥4 was associated with poor survival, as overall 3-year survival was 67% among patients with ABr ≥4 compared with 83% in those with ABr of 2 to 3.9 and 86% in those with ABr of 0 to 1.9 (P = .04).
Conclusion
Among patients with increased ABr ≥4, pre- and postoperative New York Heart Association functional class, serum N-terminal pro-brain natriuretic peptide level, and mortality were significantly increased, and ABr may thus serve as a new echocardiographic marker of high mortality risk among patients with AS treated with transcatheter aortic valve replacement.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1465-1473
Dahl Pedersen AL, Povlsen JA, Dybro A, Clemmensen TS, ... Ladefoged B, Poulsen SH
J Am Soc Echocardiogr: 29 Nov 2020; 33:1465-1473 | PMID: 32919852
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Impact:
Abstract

Factors Influencing Temporal Trends in Pediatric Inpatient Imaging Utilization.

Anderson S, Figueroa J, McCracken CE, Cochran C, ... Border WL, Sachdeva R
Background
Concern exists over exponential growth in cardiac imaging in adults, but there is paucity of such data for cardiac imaging trends in pediatric patients. The aims of this study were to determine temporal trends in the use of noninvasive cardiac imaging and compare these with trends in the use of noncardiac imaging and to identify factors influencing those trends using the Pediatric Health Information Service database.
Methods
Pediatric inpatient encounter data from January 2004 to December 2017 at 35 pediatric hospitals were extracted from the Pediatric Health Information Service database. Temporal imaging utilization trends in cardiac and noncardiac ultrasound or echocardiography, magnetic resonance imaging (MRI), and computed tomography (CT) were assessed using linear mixed-effects models. Models were adjusted for case-mix index, complex chronic conditions, patient age, length of stay, payer source, and cardiac surgical volume.
Results
A total of 5,869,335 encounters over 14 years were analyzed (median encounters per center per year, 11,411; median patient age, 4 years; median length of stay, 3 days). From 2004 to 2017, the rates of pediatric inpatient cardiac and noncardiac ultrasound and MRI increased, whereas the rate of noncardiac CT decreased. Cardiac CT use increased beginning in 2014 (+0.264 cardiac CT encounters per 1,000 encounters per year), surpassing the rate of rise of cardiac MRI. Case-mix index, cardiac surgical volume, and payer source affected the largest number of imaging trends.
Conclusions
Among pediatric inpatients, utilization of cardiac and noncardiac ultrasound and MRI has steadily increased. Noncardiac CT use declined and cardiac CT use increased after 2014. Factors influencing imaging trends include case-mix index, cardiac surgical volume, and payer source. This study lays a foundation for investigations of imaging-related resource utilization and outcomes among pediatric inpatients.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1517-1525
Anderson S, Figueroa J, McCracken CE, Cochran C, ... Border WL, Sachdeva R
J Am Soc Echocardiogr: 29 Nov 2020; 33:1517-1525 | PMID: 32919851
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Abstract

Diagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis.

Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
Background
Multimodality imaging is essential for infective endocarditis (IE) diagnosis. The aim of this work was to evaluate the agreement between transesophageal echocardiography (TEE) and cardiac computed tomography (CT) findings in patients with surgically confirmed IE.
Methods
Sixty-eight patients (mean age 63 ± 2 years) with a definite diagnosis of left-side IE according to the modified European Society of Cardiology Duke criteria, on both native and prosthetic valves, underwent TEE and cardiac CT before surgery. The presence of valvular (vegetations, erosion) and paravalvular (abscess, pseudoaneurysm) IE-related lesions were compared between both modalities. Perioperative inspection was used as reference.
Results
TEE performed better than CT in detecting valvular IE-related lesions (TEE area under the curve [AUC] = 0.881 vs AUC = 0.720, P = .02) and was similar to CT with respect to paravalvular IE-related lesions (AUC = 0.830 vs AUC = 0.816, P = .835). The ability of TEE to detect vegetation was significantly better than that of CT (AUC = 0.863 vs AUC = 0.693, P = .02). The maximum size of vegetations was moderately correlated between modalities (Spearman\'s rho = 0.575, P < .001). Computed tomography exhibited higher sensitivity than TEE for pseudoaneurysm detection (100% vs 66.7%, respectively) but was similar with respect to diagnostic accuracy (AUC = 0.833 vs AUC = 0.984, P = .156).
Conclusions
In patients with a definite diagnosis of left-side IE according to the modified European Society of Cardiology Duke criteria, TEE performed better than CT for the detection of valvular IE-related lesions and similar to CT for the detection of paravalvular IE-related lesions.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1442-1453
Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
J Am Soc Echocardiogr: 29 Nov 2020; 33:1442-1453 | PMID: 32981789
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Abstract

Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction.

Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
Background
Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography.
Methods
Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e\' ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm.
Results
LAS was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LAS was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LAS and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LAS (odds ratio, 0.78; 95% CI, 0.74-0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LAS improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01).
Conclusions
LAS has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1490-1499
Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
J Am Soc Echocardiogr: 29 Nov 2020; 33:1490-1499 | PMID: 32981787
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Abstract

Tissue Doppler-Derived Left Ventricular Systolic Velocity Is Associated with Lethal Arrhythmias in Cardiac Device Recipients Irrespective of Left Ventricular Ejection Fraction.

Barakat MF, Chehab O, Kaura A, Sunderland N, ... Scott PA, Okonko DO
Background
Life-threatening arrhythmias (LTAs) can trigger sudden cardiac death or provoke implantable cardioverter-defibrillator (ICD) discharges that escalate morbidity and mortality. Longitudinal myofibrils predominate in the subendocardium, which is uniquely sensitive to arrhythmogenic triggers. In this study, we test the hypothesis that mitral annular systolic velocity (S\'), a simple routinely obtained tissue Doppler index of LV long-axis systolic function, might predict lethal arrhythmias irrespective of left ventricular ejection fraction (LVEF).
Methods
This is a retrospective analysis of data from 302 patients (mean age, 68 years; LVEF, 32%; 77% male; 52% ischemic; 35% primary prevention; and 53% cardiac resynchronization therapy defibrillator [CRT-D]) who were followed up (median, 15 months) at two centers after receipt of an ICD or CRT-D for diverse indications. S\', averaged from tissue Doppler-derived medial and lateral mitral annular velocities, was correlated with the primary outcome of time to sustained ventricular tachycardia (VT) or fibrillation (VF) needing device therapy.
Results
The median S\' was 5.1 (interquartile range, 4.0-6.2) cm/sec and lower in CRT-D than ICD subjects (4.5 [3.8-5.6] cm/sec vs 5.5 [4.8-6.8] cm/sec, P < .001). Fifty-six (19%) subjects had LTA. Each 1 cm/sec higher S\' correlated to a 30% decreased risk of LTA (hazard ratio = 0.70; 95% CI, 0.57-0.87; P = .001) independently of age, sex, β-blocker use, center, ICD use, and LVEF. Adding S\' to the baseline Cox model improved net reclassification (P = .02). An S\' > 5.6 cm/sec was the best cutoff and linked to a 58% lower LTA risk than an S\' ≤ 5.6 cm/sec (95% CI, 0.23-0.85; P = .02).
Conclusions
A higher S\' is associated with a reduced probability of LTA in cardiac device recipients irrespective of LVEF and may have the potential to be used clinically to titrate medical, device, and ablative therapies to mitigate future arrhythmic risk.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1509-1516
Barakat MF, Chehab O, Kaura A, Sunderland N, ... Scott PA, Okonko DO
J Am Soc Echocardiogr: 29 Nov 2020; 33:1509-1516 | PMID: 33051107
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Abstract

Loeffler\'s Endocarditis: An Integrated Multimodality Approach.

Polito MV, Hagendorff A, Citro R, Prota C, ... Piscione F, Galasso G

Loeffler\'s endocarditis (LE) is the cardiac manifestation of hypereosinophilic syndrome, a rare systemic disease characterized by the sustained production of eosinophils leading to organ damage. Few data, principally by case reports, are available regarding the diagnostic workup in patients with suspected LE. Thus, we have performed a systematic search of the literature dealing with imaging in LE and propose an integrated multimodality imaging approach in the cardiac diagnostics of LE patients. The aim is to provide an updated state-of-the-art review focused on noninvasive and invasive imaging modalities for this rare and underdiagnosed disease. Standard and advanced echocardiography are typically the first cardiac imaging examinations when LE is suspected and they are also used later in follow-up for prognostic stratification and assessing response to treatment. Cardiac magnetic resonance provides a more detailed anatomical and functional evaluation of cardiac chambers, tissue characterization for the presence and extension of myocardial edema and fibrosis, and ventricular thrombi identification. Computed tomography scan and [18F]-fluoro-deoxy-glucose positron emission tomography may be helpful in selected cases to evaluate the cardiac involvement of LE as well as the other noncardiac manifestations of hypereosinophilic syndrome. Endomyocardial biopsy may be considered in patients with high clinical suspicion of LE if noninvasive imaging findings are confusing or not conclusive. The appropriate use of invasive and noninvasive imaging modalities, combining the available techniques with the patients\' clinical features, will hopefully lead to early diagnosis, more accurate staging of disease, and timely treatment of LE that may prevent the irreversible myocardial damage of LE and adverse cardiovascular events.

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

J Am Soc Echocardiogr: 29 Nov 2020; 33:1427-1441
Polito MV, Hagendorff A, Citro R, Prota C, ... Piscione F, Galasso G
J Am Soc Echocardiogr: 29 Nov 2020; 33:1427-1441 | PMID: 33129649
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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: 26 Nov 2020; epub ahead of print
Shentu W, Ozawa K, Nguyen TA, Wu MD, ... López JA, Lindner JR
J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print | PMID: 33253812
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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: 18 Nov 2020; epub ahead of print
Novo G, Santoro C, Manno G, Di Lisi D, ... Cameli M, Galderisi M
J Am Soc Echocardiogr: 18 Nov 2020; epub ahead of print | PMID: 33223357
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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: 17 Nov 2020; epub ahead of print
Bischoff AR, Giesinger RE, Rios DR, Mertens L, Ashwath R, McNamara PJ
J Am Soc Echocardiogr: 17 Nov 2020; epub ahead of print | PMID: 33220434
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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,
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: 16 Nov 2020; epub ahead of print
Soulat-Dufour L, Addetia K, Miyoshi T, Citro R, ... Lang RM,
J Am Soc Echocardiogr: 16 Nov 2020; epub ahead of print | PMID: 33212183
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Impact:
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/m) 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/m 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/m. 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/m (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/m 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/m, 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: 16 Nov 2020; epub ahead of print
Geske JB, Nordhues BD, Orme NM, Tajik AJ, Spittell PC, Ommen SR
J Am Soc Echocardiogr: 16 Nov 2020; epub ahead of print | PMID: 33212182
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Impact:
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 height 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 height 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: 16 Nov 2020; epub ahead of print
Perak AM, Khan SS, Colangelo LA, Gidding SS, ... Lima JAC, Lloyd-Jones DM
J Am Soc Echocardiogr: 16 Nov 2020; epub ahead of print | PMID: 33212181
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Impact:
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: 11 Nov 2020; epub ahead of print
Sanfilippo AJ, Kolos A, Chan K, Leong-Poi H, ... Woodward G, Yared K
J Am Soc Echocardiogr: 11 Nov 2020; epub ahead of print | PMID: 33191003
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Abstract

TEMPORARY REMOVAL: January President\'s Message.

Hung J

The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

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

J Am Soc Echocardiogr: 11 Nov 2020; epub ahead of print
Hung J
J Am Soc Echocardiogr: 11 Nov 2020; epub ahead of print | PMID: 33199250
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Abstract

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

Lopez L, Frommelt PC, Colan SD, Trachtenberg FL, ... LuAnn Minich L,
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: 10 Nov 2020; epub ahead of print
Lopez L, Frommelt PC, Colan SD, Trachtenberg FL, ... LuAnn Minich L,
J Am Soc Echocardiogr: 10 Nov 2020; epub ahead of print | PMID: 33189460
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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 [Vo] and A-Vo difference) were measured to evaluate LV and RV function, hemodynamics, and peripheral oxygen extraction (A-VO 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 Vo). 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-Vo 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-Vo 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: 10 Nov 2020; epub ahead of print
Rozenbaum Z, Ben-Gal Y, Kapusta L, Hochstadt A, ... Keren G, Topilsky Y
J Am Soc Echocardiogr: 10 Nov 2020; epub ahead of print | PMID: 33187814
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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: 08 Nov 2020; epub ahead of print
Fortuni F, Butcher SC, van der Kley F, Lustosa RP, ... Delgado V, Ajmone Marsan N
J Am Soc Echocardiogr: 08 Nov 2020; epub ahead of print | PMID: 33181281
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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: 06 Nov 2020; epub ahead of print
Liu Y, Chen B, Zhang Y, Zuo W, ... Shu X, Ge J
J Am Soc Echocardiogr: 06 Nov 2020; epub ahead of print | PMID: 33166630
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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: 05 Nov 2020; epub ahead of print
Wang Y, Zhang Y
J Am Soc Echocardiogr: 05 Nov 2020; epub ahead of print | PMID: 33166631
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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 cm) stratified by left ventricular ejection fraction (LVEF; 50%), stroke volume index (SVI; 35 mL/m), 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 cm; 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/m, 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/m (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: 04 Nov 2020; epub ahead of print
Ito S, Miranda WR, Nkomo VT, Boler AN, ... Nishimura RA, Oh JK
J Am Soc Echocardiogr: 04 Nov 2020; epub ahead of print | PMID: 33161066
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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: 01 Nov 2020; epub ahead of print
Namisaki H, Nabeshima Y, Kitano T, Otani K, Takeuchi M
J Am Soc Echocardiogr: 01 Nov 2020; epub ahead of print | PMID: 33153858
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Abstract

Left Atrial Structure and Function Predictors of New-Onset Atrial Fibrillation in Patients with Chagas Disease.

Saraiva RM, Pacheco NP, Pereira TOJS, Costa AR, ... Mediano MFF, Veloso HH
Background
Atrial fibrillation (AF) carries ominous consequences in patients with Chagas disease. The aim of this study was to determine whether left atrial (LA) volume and function assessed using three-dimensional echocardiographic (3DE) imaging and two-dimensional speckle-tracking echocardiographic deformation analysis of strain (ε) could predict new-onset AF in patients with Chagas disease.
Methods
A total of 392 adult patients with chronic Chagas disease (59% women; mean age, 53 ± 11 years) who underwent echocardiography were consecutively enrolled in this prospective longitudinal study. Echocardiographic evaluation included two-dimensional (2D) Doppler echocardiography, with evaluation of left ventricular systolic and diastolic function, LA size, and LA and left ventricular function on 3DE and ε analyses. Multivariate Cox proportional-hazards regression analysis models adjusting for age, sex, hypertension, presence of a pacemaker, and 2D Doppler echocardiographic parameters were used to test if the variables of interest had independent prognostic value for AF prediction.
Results
Patients with Chagas disease were followed for 5.6 ± 2.7 years. Among these, 139 (35.5%) had the indeterminate form, 224 (57.1%) had the cardiac form, five (1.3%) had the digestive form, and 24 (6.1%) had the cardiodigestive form. The study end point of AF occurred in 45 patients. Total LA emptying fraction (hazard ratio, 0.93; 95% CI, 0.89-0.98; P = .002), passive LA emptying fraction (HR, 0.95; 95% CI, 0.91-0.99; P = .02), and peak negative global LA ε (HR, 1.22; 95% CI, 1.05-1.41; P = .01) were predictors of new-onset AF independent of clinical and 2D Doppler echocardiographic parameters.
Conclusions
LA function assessed on 3DE and ε analyses predicts new-onset AF in patients with Chagas disease independent of clinical and 2D Doppler echocardiographic indexes.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1363-1374.e1
Saraiva RM, Pacheco NP, Pereira TOJS, Costa AR, ... Mediano MFF, Veloso HH
J Am Soc Echocardiogr: 30 Oct 2020; 33:1363-1374.e1 | PMID: 32747223
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Abstract

Right Atrial Pressure Is Associated with Outcomes in Patients with Heart Failure and Indeterminate Left Ventricular Filling Pressure.

Mele D, Pestelli G, Molin DD, Smarrazzo V, ... Flamigni F, Ferrari R
Background
In a significant proportion of patients with left-sided heart failure (HF), left ventricular filling pressure (LVFP) may not be estimated using echocardiography, so filling pressure status may remain indeterminate. In these patients, mean right atrial pressure (mRAP) has been suggested as a surrogate of LVFP. The aim of this study was to determine whether high mRAP has prognostic value in patients with HF with indeterminate pressure (IP) and whether mRAP-based reclassification of patients with IP has an impact on outcomes.
Methods
A cohort of 465 patients hospitalized with HF was retrospectively studied and divided into groups with normal pressure (n = 102), high pressure (n = 265), and IP (n = 98). A composite end point of all-cause mortality and HF rehospitalization was evaluated after a median follow-up duration of 2.5 years.
Results
There were 282 events in the entire population (53 in the normal pressure group, 173 in the high pressure group, and 56 in the IP group; P = .047). High mRAP was independently associated with outcome only in patients with IP (hazard ratio, 2.72; 95% CI, 1.25-5.9; P = .012). Evaluation of LVFP after mRAP-based reclassification of patients with IP resulted in higher risk stratification capability than current recommendations alone (log-rank χ = 15.057 vs 8.148).
Conclusions
In patients with inconclusive determination of LVFP, echocardiographic estimation of mRAP is associated with outcomes. This finding corroborates previous observation of mRAP as a surrogate marker of elevated LVFP in left-sided HF and suggests its use in clinical practice.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1345-1356
Mele D, Pestelli G, Molin DD, Smarrazzo V, ... Flamigni F, Ferrari R
J Am Soc Echocardiogr: 30 Oct 2020; 33:1345-1356 | PMID: 32741596
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Abstract

Longitudinal Variation in Presence and Severity of Cardiac Valve Regurgitation in Healthy Children.

Colan SD, Sleeper LA
Background
The goal of this study was to document the frequency and longitudinal variation in the presence and severity of echocardiographically documented valvular regurgitation (VR) in healthy children free of evidence of heart disease. We hypothesized that significant variation is common, and our specific aim was to determine change in prevalence and severity of VR in children free of heart disease.
Methods
The presence of VR was documented on each of the four valves, and the severity of regurgitation was assessed as the body surface area (BSA)-adjusted width of the vena contracta on each of two sequential echocardiograms in healthy children free of clinical and echocardiographic evidence of heart disease.
Results
We included 200 children ages 10.0 ± 4.5 years, BSA = 1.2 ± 0.43 m, at the first exam and 12.8 ± 4.9 years, BSA = 1.42 ± 0.44 m, at the second exam. Frequency of VR was similar on the two exams (tricuspid = 61.5% vs 57.0%, pulmonary = 55.5 vs 57.5%, mitral = 14.5% vs 16.0%, aortic = 3.0 vs 3.5%). The frequency of new appearance was similar to the frequency of resolution of VR for all four valves. For instances where the severity of VR was classified as trace versus mild, the frequency of change from mild to trace between the two exams was similar to the frequency of change from trace to mild.
Conclusions
In healthy children with no evidence of heart disease, there is substantial temporal variation in the presence and severity of tricuspid and pulmonary VR. The prevalence of mitral and aortic VR is lower in healthy children, but temporal variation is also noted for these valves. The finding of new-onset echocardiographic trace or mild VR cannot be assumed to represent incident valve pathology.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1400-1406
Colan SD, Sleeper LA
J Am Soc Echocardiogr: 30 Oct 2020; 33:1400-1406 | PMID: 32741595
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Abstract

Speckle-Tracking Echocardiography for the Assessment of Atrial Function during Fetal Life.

Rato J, Vigneswaran TV, Simpson JM
Introduction
Speckle-tracking echocardiography has become a major tool in the evaluation of heart function. Atrial strain has emerged as an important component in the assessment of cardiac function, but there is a paucity of prenatal data. The aim of this study was to describe our initial experience of measurement of atrial strain in fetuses, with respect to both feasibility and the strain patterns observed.
Methods
Four-chamber Digital Imaging and Communications in Medicine loops were acquired prospectively for deformation imaging. Fifty-three normal fetuses with no morphologic or functional abnormalities were selected for analysis. The three strain components of atrial cycle for both left atrium (LA) and right atrium (RA) were acquired-reservoir (LAres or RAres), conduit, and contraction (LAct or RAct)-and are expressed as a percentage. Ratios of these components were calculated. Simple linear regression was used to analyze how the dependent variables changed according to gestational age and frame rate.
Results
The median gestational age was 30 weeks (range, 23-35), and the frame rate was 74 frames per second (fps; range, 35-121). Left atrial strain was feasible in 48/53 (91%), and right atrial strain in 46/53 (87%) of cases. The onset of LA contraction could be identified on the strain curves in 32 of 48 (67%) cases, and of the RA in 17 of 46 (37%) cases. The values of RAres and RAct were higher compared with those of LAres and LAct (33.9% vs 30.3%, P = .014; and 21.5% vs 16.8%, P = .005), and the contraction:reservoir ratio was also higher for RA (0.63 vs 0.55 for LA, P = .003). Higher values for LAres, LAct, RAres, and RAct were associated with higher frame rate (P = .007, .020, .049, and .012, respectively). The onset of LA contraction was better identified with a higher frame rate (mean 77 vs 59 fps when not seen, P = .007). A higher LA contraction:reservoir ratio was associated with a lower gestational age (P = .042).
Conclusion
Measurement of atrial strain is feasible in the fetal heart. The values are influenced by gestational age and frame rate, so it is necessary to account for these variables. Comparison of left versus right atrial strain values contrasts with those observed postnatally. Atrial function merits further study during fetal life, to aid understanding of maturational changes and disease states.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1391-1399
Rato J, Vigneswaran TV, Simpson JM
J Am Soc Echocardiogr: 30 Oct 2020; 33:1391-1399 | PMID: 32828625
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Abstract

Transcatheter Aortic Valve Replacement and Left Ventricular Geometry: Survival and Gender Differences.

Truong VT, Mazur W, Broderick J, Egnaczyk GF, ... Bartone C, Chung ES
Background
The aim of this study was to examine the relationship between baseline left ventricular (LV) geometry and outcomes after transcatheter aortic valve replacement (TAVR).
Methods
Patients undergoing TAVR (n = 206) had baseline LV geometry classified as (1) concentric hypertrophy, (2) eccentric hypertrophy, (3) concentric remodeling, or (4) normal. Descriptive statistics, Kaplan-Meier time-to-event analysis, and Cox regression were performed.
Results
Distribution of baseline LV geometry differed between male and female patients (χ = 16.83, P = .001) but not at 1 month (χ = 2.56, P = .47) or 1 year (χ = 5.68, P = .13). After TAVR, a majority of patients with concentric hypertrophy evolved to concentric remodeling. Survival differed across LV geometry groups at 1 year (χ[3] = 8.108, P = .044, log-rank test) and at 6.5 years (χ[3] = 9.023, P = .029, log-rank test). Compared with patients with concentric hypertrophy, patients with normal geometry (hazard ratio, 2.25; 95% CI, 1.12-4.54; P = .023) and concentric remodeling (hazard ratio, 1.89; 95% CI, 1.12-3.17; P = .016) had higher rates of all-cause mortality.
Conclusions
Baseline concentric hypertrophy confers a survival advantage after TAVR. Although baseline patterns of LV geometry appear gender specific (with women demonstrating more concentric hypertrophy), this difference resolves after TAVR.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1357-1362.e2
Truong VT, Mazur W, Broderick J, Egnaczyk GF, ... Bartone C, Chung ES
J Am Soc Echocardiogr: 30 Oct 2020; 33:1357-1362.e2 | PMID: 32828622
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Abstract

Impact of Arterial Blood Pressure on Ultrasound Hemodynamic Assessment of Aortic Valve Stenosis Severity.

Hayek A, Derimay F, Green L, Rosset M, ... Rioufol G, Finet G
Background
Aortic stenosis (AS) severity assessment is based on several indices. Aortic valve area (AVA) is subject to inaccuracies inherent to the measurement method, while velocities and gradients depend on hemodynamic status. There is controversy as to whether blood pressure directly affects common indices of AS severity.
Objectives
The study objective was to assess the effect of systolic blood pressure (SBP) variation on AS indices, in a clinical setting.
Methods
A prospective, single-center study included 100 patients with at least moderately severe AS with preserved left ventricle ejection fraction. Patients underwent ultrasound examination during which AS severity indices were collected, with three hemodynamic conditions: (1) low SBP: <120 mm Hg; (2) intermediate SBP: between 120 and 150 mm Hg; (3) high SBP: ≥150 mm Hg. For each patient, SBP profiles were obtained by injection of isosorbide dinitrate or phenylephrine.
Results
At baseline state, 59% presented a mean gradient (G) ≥ 40 mm Hg, 44% a peak aortic jet velocity (V) ≥4 m/sec, 66% a dimensionless index (DI) ≤0.25, and 87% an indexed AVA (AVAi) ≤ 0.6 cm/m. Compared with intermediate and low SBP, high SBP induced a significant decrease in G (39 ± 12 vs 43 ± 12 and 47 ± 12 mm Hg, respectively; P < .05) and in V (3.8 ± 0.6 vs 4.0 ± 0.6 and 4.2 ± 0.6 mm Hg; P < .05). Compared with the baseline measures, in 16% of patients with an initial G< 40 mm Hg, gradient rose above 40 mm Hg after optimization of the afterload (low SBP; P < .05). Conversely, DI and AVAi did not vary with changes in hemodynamic conditions. Flow rate, not stroke volume was found to impact G and V but not AVA and DI (P < .05).
Conclusions
Hemodynamic conditions may affect the AS ultrasound assessment. High SBP, or afterload, leads to an underestimation of AS severity when based on gradients and velocities. Systolic blood pressure monitoring and control are crucial during AS ultrasound assessment.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1324-1333
Hayek A, Derimay F, Green L, Rosset M, ... Rioufol G, Finet G
J Am Soc Echocardiogr: 30 Oct 2020; 33:1324-1333 | PMID: 32868157
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Abstract

Stereoscopic Display Is Superior to Conventional Display for Three-Dimensional Echocardiography of Congenital Heart Anatomy.

Harake D, Gnanappa GK, Alvarez SGV, Whittle A, ... Noga M, Khoo NS
Background
Three-dimensional echocardiography (3DE) improves visualization of cardiac lesions. Current viewing of 3DE studies on a conventional display diminishes the encoded stereoscopic (stereo) information for depth perception. This study aims to evaluate clinician subjective and objective experience of stereo display compared with nonstereo display of 3DE in congenital heart disease.
Methods
In this prospective study, 22 cardiologists, advanced cardiology trainees, and cardiothoracic surgeons used a commercially available stereo display system with proprietary software to view 10 3DE data sets, alternating between simple and complex lesions. In part A, participants viewed each data set, randomized to 1 minute of stereo display followed by 1 minute of nonstereo display, or vice versa. In part B, participants could freely toggle between stereo and nonstereo display for an additional 90 seconds per data set. Participants answered a series of questions and rated their subjective experience using stereo versus nonstereo display mode on a Likert scale. Objective data on time spent in each display mode during part B and duration of interaction and degree of movement of the 3DE data set in parts A and B were also collected.
Results
All clinician groups found stereo display preferable to nonstereo display of 3DE (P < .0001). Viewing complex lesions was rated lower than simple lesions when using nonstereo display (P < .01). Simple and complex lesions were equally well rated when using stereo display (P = .14). When given a choice of display modes in part B, participants spent more time in stereo display (P < .0001) and interacted more with the 3DE data sets in stereo display (P < .0001).
Conclusions
Interactive stereoscopic display of 3DE was preferred over conventional nonstereo display by all clinician groups for viewing both simple and complex lesions. This preference is especially true for viewing complex lesions.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1297-1305
Harake D, Gnanappa GK, Alvarez SGV, Whittle A, ... Noga M, Khoo NS
J Am Soc Echocardiogr: 30 Oct 2020; 33:1297-1305 | PMID: 32919855
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Abstract

Improved Delineation of Cardiac Pathology Using a Novel Three-Dimensional Echocardiographic Tissue Transparency Tool.

Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
Background
Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering.
Methods
We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation.
Results
TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05).
Conclusions
The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1316-1323
Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 30 Oct 2020; 33:1316-1323 | PMID: 32972777
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Abstract

Virtual Reality Analysis of Three-Dimensional Echocardiographic and Cardiac Computed Tomographic Data Sets.

Narang A, Hitschrich N, Mor-Avi V, Schreckenberg M, ... Lang RM, Mumm B
Background
Three-dimensional echocardiographic (3DE) imaging and cardiac computed tomographic (CCT) imaging are important cardiac imaging tools. Despite the three-dimensional nature of these image acquisitions and reconstructions, they are visualized on two-dimensional monitors with shading and coloring to create the illusion of three dimensions. Virtual reality (VR) is a novel tool that allows true three-dimensional visualization and manipulation. The aims of this study were to test the feasibility of converting 3DE and CCT data into three-dimensional VR models, compare the variability of measurements performed in VR and conventional software, assess the diagnostic quality of VR models, and understand the value of VR over conventional viewing.
Methods
Custom software with clinically relevant postprocessing tools (interactively adjustable visualization parameters, multiplanar reconstructions, cropping planes, and nonplanar measurements) was developed to convert 3DE and CCT data into VR models. Anatomic measurements of 15 3DE and 15 CCT data sets of the mitral valve were compared using conventional software and in the VR environment. Additionally, the diagnostic quality of the VR models created from 3DE and CCT data sets was assessed.
Results
The 3DE and CCT data sets were successfully converted into VR models in <3 min. The measurement variabilities were reduced by 40% (20.1% vs 12.2%) for 3DE imaging and 34% (15.3% vs 10.1%) for CCT imaging by using VR. The mean time needed for measurements was reduced by 31% (from 61 to 42 sec) for 3DE imaging and 39% (from 37 to 23 sec) for CCT imaging. Most users reported facile manipulation of VR models, diagnostic quality visualization of the anatomy, and high confidence in the measurements.
Conclusions
This study demonstrates the feasibility of converting 3DE and CCT data into diagnostic-quality VR models. Compared with conventional imaging, VR analysis is associated with faster navigation and accurate measurements with lower variability.

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

J Am Soc Echocardiogr: 30 Oct 2020; 33:1306-1315
Narang A, Hitschrich N, Mor-Avi V, Schreckenberg M, ... Lang RM, Mumm B
J Am Soc Echocardiogr: 30 Oct 2020; 33:1306-1315 | PMID: 32981791
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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: 29 Oct 2020; epub ahead of print
Brainin P, Biering-Sørensen T, Jensen MT, Møgelvang R, ... Rossing P, Jørgensen PG
J Am Soc Echocardiogr: 29 Oct 2020; epub ahead of print | PMID: 33132020
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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: 29 Oct 2020; epub ahead of print
Chen W, Saxon DT, Henry MP, Herald JR, ... Gurm HS, Bhave NM
J Am Soc Echocardiogr: 29 Oct 2020; epub ahead of print | PMID: 33139140
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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, 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: 28 Oct 2020; epub ahead of print
Deferm S, Bertrand PB, Churchill TW, Sharma R, ... Schwamm LH, Yoerger Sanborn DM
J Am Soc Echocardiogr: 28 Oct 2020; epub ahead of print | PMID: 33132019
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Abstract

Umbilical and Middle Cerebral Artery Doppler Measurements in Fetuses With Congenital Heart Block.

Pisesky A, Luo ZC, Jaeggi E, Ryan G, Keunen J, Van Mieghem T
Objectives
In fetal congenital complete heart block, the slow fetal heart rate prolongs the diastolic phase of the cardiac cycle, which may affect Doppler measurements that are typically used to quantify placental function. We here describe the umbilical artery (UA) and middle cerebral artery (MCA) Dopplers in a cohort of fetuses with heart block, hypothesizing that values will be increased but nevertheless remain associated with placental function and fetal outcome.
Methods
We retrospectively reviewed Doppler measurements of the UA and MCA pulsatility index (PI) and resistance index in fetuses with complete heart block. The cerebroplacental ratio (CPR) was calculated as a marker of central redistribution. Measurements were transformed to Z scores and compared between fetuses born with a normal weight (appropriate for gestational age [AGA]) to those with fetal growth restriction (FGR) and correlated with a composite adverse outcome consisting of FGR, fetal death, or preterm birth prior to 34 weeks\' gestation.
Results
Fifty-four fetuses were included. There were 36 (67%) live births, 8 (22%) stillbirths, and 10 (19%) pregnancy terminations. Of those born alive, 14 (39%) had FGR. The UA PI decreased with gestational age and was higher in FGR compared with AGA fetuses (P < .001). Twenty-three percent of AGA fetuses developed absent end-diastolic flow in the UA. The MCA PI did not change with gestation and did not differ between AGA and FGR fetuses. The CPR was lower in FGR than in AGA fetuses (-2.43 ± 0.85 vs -1.44 ± 1.04, P = .006). The UA PI and resistance index were strongly correlated with the composite adverse outcome (P < .001).
Conclusions
The UA and MCA PI are significantly elevated in fetuses with complete heart block. The UA Doppler indices and CPR nevertheless still reflect placental function. Longitudinal measurements may be useful in monitoring well-being in fetuses with heart block.

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

J Am Soc Echocardiogr: 26 Oct 2020; epub ahead of print
Pisesky A, Luo ZC, Jaeggi E, Ryan G, Keunen J, Van Mieghem T
J Am Soc Echocardiogr: 26 Oct 2020; epub ahead of print | PMID: 33127209
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Abstract

The Diagnostic Value of Radial and Carotid Intima Thickness Measured by High-Resolution Ultrasound for Ischemic Stroke.

Xu M, Jin S, Li F, Jia G, ... Zhang M, Zhang Y
Background
No study has examined intima thickness of the carotid artery and peripheral arteries in subjects with acute ischemic stroke due to large-artery atherosclerosis (LAAS). The aim of this study was to test whether carotid intima thickness (CIT), radial intima thickness (RIT), and dorsalis pedis intima thickness (PIT) are closely associated to atherosclerotic risk factors and whether they possess independent and additive value for differentiating LAAS stroke.
Methods
One hundred and two patients with LAAS stroke and 104 age- and gender-matched control subjects were enrolled. CIT, RIT, and PIT were measured using a 24-MHz, high-resolution ultrasound system. Multivariate linear regression was performed to determine associations between ultrasonic parameters and risk factors. Binary logistic regression was used to evaluate the diagnostic value of different parameters. Receiver operating characteristic curves were plotted to compare the performance of several diagnostic models.
Results
CIT ([36.97 ± 11.27] × 10 vs [23.68 ± 5.12] × 10 mm, P < .001) and RIT ([15.40 ± 3.62] × 10 vs [11.06 ± 2.22] × 10 mm, P < .001) were significantly thicker in patients with LAAS stroke than in control subjects. CIT and RIT were associated with traditional risk factors for atherosclerosis, including age, systolic blood pressure, and serum levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, homocysteine, and glucose. CIT had incremental diagnostic value to traditional risk factors for LAAS stroke (area under the curve, 0.945 vs 0.860; P = .006). The addition of CIT and RIT to traditional risk factors had the best diagnostic performance (area under the curve, 0.961).
Conclusions
Measurement of CIT, RIT, and PIT is feasible and reliable using newly developed ultrasound techniques. CIT and RIT were associated with traditional risk factors for atherosclerosis and exhibited incremental value to traditional risk factors for differentiating patients with LAAS stroke from control subjects.

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

J Am Soc Echocardiogr: 25 Oct 2020; epub ahead of print
Xu M, Jin S, Li F, Jia G, ... Zhang M, Zhang Y
J Am Soc Echocardiogr: 25 Oct 2020; epub ahead of print | PMID: 33121857
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This program is still in alpha version.