Journal: J Am Soc Echocardiogr

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Abstract

Routine Use of Contrast at Admission Transthoracic Echocardiogram for Heart Failure Reduces the Rate of Repeat Echocardiograms During Index Admission.

Lee KC, Liu S, Callahan P, Green T, ... Flueckiger P, Vannan MA
Background
We retrospectively evaluated the impact of UEA use in the first TTE, regardless of the baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a HF admission.
Methods
There were 9,115 HF admissions associated with an admission TTE over a 4 year period (5,337 men; mean age 67.6 ± 15.0 years). Patients were grouped into those who received a UEA (contrast group) in the first TTE and those who did not (non-contrast group). Repeat TTEs were classified as justified if performed for concrete clinical indications during hospitalization.
Results
In the 9,115 admissions for HF (n = 5,600 contrast group, 3,515 non-contrast group) 927 patients had repeat TTEs (n = 505 contrast group, 422 non-contrast group), which was considered justified in 823 patients. Of the 104 patients who had unjustified repeat TTEs, 80 belonged to the non-contrast group (76.7%) and 24 belonged to the contrast group. Also, UEA usage increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeats decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE were 2.3% and 0.4% (non-contrast and contrast groups, respectively), and patients in the contrast group were less likely to receive an unjustified repeat echo (OR = 0.18, 95% CI: 0.12 to 0.29, p < 0.0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 days versus 11.1 ± 13.7 days). The use of UEA in the first TTE was also associated with a reduced LOS (linear regression, β1 = -0.47, p = 0.036), with 20% lower odds for odds of prolonged (>6 days) LOS.
Conclusions
The routine use of UEA in the first TTE for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 16 Jul 2021; epub ahead of print
Lee KC, Liu S, Callahan P, Green T, ... Flueckiger P, Vannan MA
J Am Soc Echocardiogr: 16 Jul 2021; epub ahead of print | PMID: 34284098
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Abstract

2D Echocardiographic Right Ventricular Size and Systolic Function Measurements Stratified by Sex, Age and Ethnicity: Results of the World Alliance of Societies of Echocardiography Study.

Addetia K, Miyoshi T, Citro R, Daimon M, ... Lang RM, WASE Investigators
Background
Echocardiographic assessment of right ventricular (RV) systolic function is an important component of clinical decision-making. While societal guidelines have worked to define normal ranges of RV size and function, they have not included the impact of age, sex and ethnicity on these parameters, as they have for the left ventricle. The World Alliance of Societies of Echocardiography (WASE) study was designed to investigate the effect of age, sex and ethnicity on all cardiac chambers. In this study, we sought to explore whether these differences exist for RV systolic parameters.
Methods
Adequate 2D RV focused-views for measurement of systolic parameters, including fractional area change (FAC), global and free-wall longitudinal strain (GLS, FWS) were available in 1913 subjects (47±17 years; 51% male). Basal and mid-RV dimensions, length, tricuspid annular peak systolic excursion (TAPSE), tissue Doppler S\' velocity and myocardial performance index (MPI) were also measured. Subjects were grouped by age (<40, 41-65, >65 years), with results also stratified by sex and ethnicity (Asian, Black or White) and analyzed using vendor-independent software. Differences between groups were evaluated using ANOVA.
Results
Women had smaller absolute and indexed RV areas, absolute RV dimensions and higher magnitude FAC, FWS and GLS, compared to men. With respect to age, most of the statistically significant differences were noted between the <40 and >65 age groups, with RV areas and length smaller in older age groups and RV functional parameters (S\', FAC, TAPSE, GLS, FWS and MPI) showing minimal decrease or no change with age. While there were no meaningful differences in functional parameters between ethnic groups, RV size was smallest in Asians.
Conclusions
Our findings suggest that while 2D RV parameters are age- and sex-dependent, association with race is less apparent, excepting that the Asian population appears to have smaller chamber sizes when compared with whites and blacks.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 14 Jul 2021; epub ahead of print
Addetia K, Miyoshi T, Citro R, Daimon M, ... Lang RM, WASE Investigators
J Am Soc Echocardiogr: 14 Jul 2021; epub ahead of print | PMID: 34274451
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Abstract

Association of Left Atrial Metrics with Atrial Fibrillation Rehospitalization and Adverse Cardiovascular Outcomes in Patients with Non-valvular Atrial Fibrillation following Index Hospitalization.

Bhat A, Gan GCH, Chen HHL, Khanna S, ... MacIntyre CR, Tan TC
Background
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice with significant clinical and economic burdens, largely driven by adverse cardiovascular outcomes and AF-related hospitalization. Left atrial (LA) parameters have been shown to have prognostic value in cardiovascular disease states. We sought to evaluate the prognostic value of measures of LA size and function, as measured through LA volume index (LAVI) and LA emptying fraction (LAEF) respectively, for AF rehospitalization and long-term adverse outcomes in patients with non-valvular AF following index hospitalization.
Methods
In this retrospective study, 594 consecutive patients (mean age 67.8±13.6 years, 53% men) admitted to a tertiary referral centre with non-valvular AF were assessed. Patients who underwent transthoracic echocardiography during their index admission and had complete follow-up data were included and followed for a mean period of 33.18 ± 21.27 months for the primary outcome of AF rehospitalization. The secondary outcome was a composite of all-cause death and major adverse cardiovascular events (MACE).
Results
The primary outcome occurred in 250 (42%) patients and the secondary outcome occurred in 219 (37%) patients. On multivariable regression analysis, LAEF had an independent association with AF rehospitalization (hazard ratio [HR] 0.967, CI0.953 - 0.982, p<0.01) and time dependent receiver operating characteristic curves demonstrated LAEF to have strong diagnostic accuracy in predicting early and intermediate AF rehospitalization. Both LAVI (HR 1.014, CI 1.003 - 1.026, p=0.01) and LAEF (HR 0.982, CI 0.970 - 0.993, p<0.01) were associated with all-cause death and MACE.
Conclusions
Adverse LA remodelling, as reflected through LA enlargement and reduced LA mechanical function, is associated with AF rehospitalization and long-term adverse cardiovascular outcomes in hospitalized patients with non-valvular AF.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Jul 2021; epub ahead of print
Bhat A, Gan GCH, Chen HHL, Khanna S, ... MacIntyre CR, Tan TC
J Am Soc Echocardiogr: 06 Jul 2021; epub ahead of print | PMID: 34245827
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Abstract

Automated Pattern Recognition in Whole-Cardiac Cycle Echocardiographic Data - Capturing Functional Phenotypes with Machine Learning.

Loncaric F, Castellote PM, Sanchez-Martinez S, Fabijanovic D, ... Sitges M, Bijnens B
Background
Echocardiography provides complex data on cardiac function that can be integrated into patterns of dysfunction related to the severity of cardiac disease. The aim is to demonstrate the feasibility of applying machine learning (ML) to automate the integration of echocardiographic data from the whole cardiac cycle, and to automatically recognize patterns in velocity profiles and deformation curves, allowing for identification of functional phenotypes.
Methods
An echocardiogram was performed in 189 clinically managed hypertensive patients, and 97 non-hypertensive healthy individuals. Speckle-tracking analysis of the left ventricle (LV) and atrium was performed and deformation curves extracted. The aortic and mitral blood pool pulsed-wave (PW) Doppler and the mitral annular tissue PW Doppler velocity profiles were obtained. These whole cardiac cycle deformation and velocity curves were used as the ML input. Unsupervised ML was used to create a representation of hypertensive patients in a virtual space where patients are positioned based on the similarity of their integrated whole cardiac cycle echo data. Regression methods were used to explore patterns of echocardiographic traces within this virtual ML-derived space, while clustering was used to define phenogroups.
Results
The algorithm captured different patterns in tissue/blood-pool velocity and deformation profiles, and integrated the findings, yielding phenotypes related to normal cardiac function and others to advanced remodeling associated with pressure overload in hypertension. The addition of non-hypertensive individuals into the ML-derived space confirmed the interpretation of normal and remodeled phenotypes.
Conclusions
ML-based pattern recognition is feasible from echocardiographic data obtained during the whole cardiac cycle. Automated algorithms can consistently capture patterns in velocity and deformation data, and, on the basis of these patterns, group patients into interpretable, clinically comprehensive phenogroups that describe structural and functional remodeling. Automated pattern recognition may potentially aid interpretation of imaging data and diagnostic accuracy.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Jul 2021; epub ahead of print
Loncaric F, Castellote PM, Sanchez-Martinez S, Fabijanovic D, ... Sitges M, Bijnens B
J Am Soc Echocardiogr: 06 Jul 2021; epub ahead of print | PMID: 34245826
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Abstract

Ultrasound Imaging of the Abdominal Aorta:A Comprehensive Review.

Fadel BM, Mohty D, Kazzi BE, Alamro B, ... Echahidi N, Aboyans V
Ultrasound is the imaging modality of choice for the initial evaluation of disorders that involve the abdominal aorta (AA). The diagnostic value of ultrasound resides in its ability to allow assessment of the anatomy and structure of the AA using two- dimensional, three-dimensional, and contrast enhanced imaging. Moreover, ultrasound permits evaluation of the physiological and hemodynamic consequences of abnormalities through Doppler interrogation of blood flow, thus enabling the identification and quantification of disorders within the AA and beyond its boundaries. The approach to ultrasound imaging of the AA varies, depending on the purpose of the study and whether it is performed in a radiology / vascular laboratory or in an echocardiography laboratory. The aim of this review is to demonstrate the usefulness of ultrasound imaging for the detection and evaluation of disorders that involve the AA, detail the abnormalities that are detected or further assessed, and outline its value for echocardiographers, sonographers and radiologists.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 01 Jul 2021; epub ahead of print
Fadel BM, Mohty D, Kazzi BE, Alamro B, ... Echahidi N, Aboyans V
J Am Soc Echocardiogr: 01 Jul 2021; epub ahead of print | PMID: 34224827
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:775-785
White BR, Faerber JA, Katcoff H, Glatz AC, Mascio CE, Cohen MS
J Am Soc Echocardiogr: 29 Jun 2021; 34:775-785 | PMID: 33600926
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Abstract

Intervendor Agreement for Right Ventricular Global Longitudinal Strain in Children.

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:786-793
Aly D, Ramlogan S, France R, Schmidt S, ... Goudar SP, Forsha D
J Am Soc Echocardiogr: 29 Jun 2021; 34:786-793 | PMID: 33561494
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:735-743
Mann TD, Loewenstein I, Ben Assa E, Topilsky Y
J Am Soc Echocardiogr: 29 Jun 2021; 34:735-743 | PMID: 33652083
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:709-722.e1
Silbiger JJ
J Am Soc Echocardiogr: 29 Jun 2021; 34:709-722.e1 | PMID: 33652082
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:723-734
Murayama M, Iwano H, Nishino H, Tsujinaga S, ... Nagai T, Anzai T
J Am Soc Echocardiogr: 29 Jun 2021; 34:723-734 | PMID: 33675942
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:757-766.e8
Melki L, Wang DY, Grubb CS, Weber R, ... Garan H, Konofagou EE
J Am Soc Echocardiogr: 29 Jun 2021; 34:757-766.e8 | PMID: 33675941
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:767-774
Mora V, Roldán I, Bertolín J, Faga V, ... Arbucci R, Lowenstein J
J Am Soc Echocardiogr: 29 Jun 2021; 34:767-774 | PMID: 33744403
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jun 2021; 34:744-756
Buck T, Eiswirth N, Farah A, Kahlert H, ... Kahlert P, Plicht B
J Am Soc Echocardiogr: 29 Jun 2021; 34:744-756 | PMID: 33722676
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Abstract

Computational analysis of virtual echocardiographic assessment of functional mitral regurgitation for validation of proximal isovelocity surface area (PISA) methods.

Qin T, Caballero A, Hahn RT, McKay R, Sun W
Background
Mitral regurgitation (MR) quantification by proximal isovelocity surface area (PISA) method remains challenging. Using computer models, this study aims to evaluate the accuracy of different PISA methods and quantify their errors.
Methods
Five functional MR (FMR) computer models of different geometric and tethering abnormalities were created, validated and treated as phantom models, from which the reference values were directly obtained. Virtual 2D and 3D PISA (both peak and integrated values) were performed on these phantom models. By comparing virtual PISA results with reference values, the accuracy of different PISA methods was evaluated, and their sources of errors were quantified.
Results
Compared to reference values of regurgitant flow rate, excellent correlations were found for true-PISA (r = 0.99, bias 32.3 ± 35.3 ml/s), 3D-PISA (r = 0.97, bias -24.4 ± 55.5 ml/s), followed by multiplane 2D hemicylindrical (HC)-PISA (r = 0.88, bias -24.1 ± 85.4 ml/s), hemiellipsoidal (HE)-PISA (r = 0.91, bias -55.7 ± 96.6 ml/s). Weaker correlations were found for single plane 2D hemispherical (HS)-PISA (PLAX: r = 0.71, bias -77.6 ± 124.5 ml/s; A2Ch: r = 0.69, bias -52.0 ± 122.0 ml/s; A4Ch: r = 0.82, bias -65.5 ± 107.3 ml/s). For regurgitant volume quantification, integrated PISA was more accurate than peak PISA. The bias of 3D PISA improved from -12.7 ± 7.8 ml (peak PISA) to -2.1 ± 5.3 ml (integrated PISA).
Conclusions
For FMR quantification, 2D HS-PISA had significant underestimation, multiplane 2D HE- and HC-PISA showed improve accuracy, while 3D-PISA is the most accurate. PISA method is subject to both systematic underestimation due to Doppler angle effect, and systematic overestimation when regurgitant flow is not perpendicular to PISA contour. Integrated PISA is able to capture the dynamic MR and is therefore more accurate than peak PISA. The sum of regurgitant flow rates is the most feasible way to perform integrated PISA.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 28 Jun 2021; epub ahead of print
Qin T, Caballero A, Hahn RT, McKay R, Sun W
J Am Soc Echocardiogr: 28 Jun 2021; epub ahead of print | PMID: 34214636
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Impact:
Abstract

Aging athlete\'s heart: An echocardiographic evaluation of competitive sprint- vs endurance-trained master athletes.

Kusy K, Błażejewski J, Gilewski W, Karasek D, ... Sinkiewicz W, Grześk G
Background
Sports training triggers exercise-induced cardiac remodeling (EICR). Sprint- and endurance-trained master athletes are exposed to different hemodynamic stimuli accompanied by aging. We aimed to compare EICR types in light of the Morganroth hypothesis, frequency of abnormalities, and relationships between cardiac traits and age.
Methods
In our observational cross-sectional study, we performed echocardiographic examinations in 142 sprint-trained (36‒83 years) and 114 endurance-trained (38‒85 years) competitive master athletes. We compared structural and functional characteristics to population reference values and identified EICR types. Athletic groups were compared using t-test and chi-squared test. Relationships with age were assessed using linear regression.
Results
In the sprint group, 51.0% of athletes had normal cardiac geometry (non-hypertrophic heart), 4.2% eccentric hypertrophy, 36.4% concentric remodeling, and 8.4% concentric hypertrophy. In their endurance peers, the proportions were 22.8%, 16.7%, 36.8%, and 23.7%, respectively. Many athletes in both groups had structural abnormalities as assessed using population norms (up to ∼81% for septal thickness) but their resting cardiac function was normal. The relationships of structural and functional cardiac characteristics with age were mostly weak to moderate and did not differ between training modalities.
Conclusions
Even though many endurance- and sprint-oriented master athletes exceed population norms for cardiac structure, they do not go beyond the \'gray zone\' and preserve normal cardiac function. Therefore, physiological adaptations, rather than pathological abnormalities, are expected in aging but still active athletes. Inconsistent with the Morganroth hypothesis, EICR is shifted toward normal geometry in sprinters and concentric remodeling/hypertrophy in endurance runners. A better understanding of the mechanisms behind cardiac remodeling during aging is needed to adequately predict EICR types in master athletes.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Jun 2021; epub ahead of print
Kusy K, Błażejewski J, Gilewski W, Karasek D, ... Sinkiewicz W, Grześk G
J Am Soc Echocardiogr: 23 Jun 2021; epub ahead of print | PMID: 34175421
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Impact:
Abstract

Clinical Significance of Global Wasted Work in Patients with Heart Failure Receiving Cardiac Resynchronization Therapy.

Riolet C, Menet A, Mailliet A, Binda C, ... Tribouilloy C, Marechaux S
Background
The relationship between myocardial work assessment using pressure-strain loops by echocardiography before cardiac resynchronization therapy (CRT) and response to CRT has been recently revealed. Among myocardial work parameters, the impact of left ventricular myocardial global wasted work (GWW) on response to CRT and outcome following CRT has been seldom studied. Hence, the authors evaluated the relationship between preprocedural GWW and outcome in a large prospective cohort of patients with heart failure (HF) and reduced ejection fraction receiving CRT.
Methods
The study included 249 patients with HF. Myocardial work indices including GWW were calculated using speckle-tracking strain two-dimensional echocardiography using pressure-strain loops. End points of the study were (1) response to CRT, defined as left ventricular reverse remodeling and/or absence of hospitalization for HF, and (2) all-cause death during follow-up.
Results
Median follow-up duration was 48 months (interquartile range, 43-54 months). Median preoperative GWW was 281 mm Hg% (interquartile range, 184-388 mm Hg%). Preoperative GWW was associated with CRT response (area under the curve, 0.74; P < .0001), and a 200 mm Hg% threshold discriminated CRT nonresponders from responders with 85% specificity and 50% sensitivity, even after adjustment for known predictors of CRT response (adjusted odds ratio, 4.03; 95% CI, 1.91-8.68; P < .001). After adjustment for established predictors of outcome in patients with HF with reduced ejection fraction receiving CRT, GWW < 200 mm Hg% remained associated with a relative increased risk for all-cause death compared with GWW ≥ 200 mm Hg% (adjusted hazard ratio, 2.0; 95% CI, 1.1-3.9; P = .0245). Adding GWW to a baseline model including known predictors of outcome in CRT resulted in an improvement of this model (χ2 to improve 4.85, P = .028). The relationship between GWW and CRT response and outcome was stronger in terms of size effect and statistical significance than for other myocardial work indices.
Conclusions
Low preoperative GWW (<200 mm Hg%) is associated with absence of CRT response in CRT candidates and with a relative increased risk for all-cause death. GWW appears to be a promising parameter to improve selection for CRT of patients with HF with reduced ejection fraction.

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

J Am Soc Echocardiogr: 18 Jun 2021; epub ahead of print
Riolet C, Menet A, Mailliet A, Binda C, ... Tribouilloy C, Marechaux S
J Am Soc Echocardiogr: 18 Jun 2021; epub ahead of print | PMID: 34157400
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Impact:
Abstract

Tricuspid valve tethering is associated with residual regurgitation after valve repair in hypoplastic left heart syndrome: a three-dimensional echocardiography study.

Shigemitsu S, Mah K, Thompson RB, Grenier J, ... Khoo NS, Colen T
Background
Tricuspid regurgitation (TR) is a risk factor for morbidity and mortality in children with hypoplastic left heart syndrome (HLHS). Surgical tricuspid valve (TV) repair is common but durable repair remains challenging. This study examines mechanisms of TR requiring surgery, features associated with unsuccessful repair, and TV changes after surgical repair.
Methods
We assessed 36 patients with HLHS requiring TV repair (TVR) and 36 matched HLHS controls using two-dimensional and three-dimensional echocardiography (2DE and 3DE). Using 3DE, TV coordinates from annulus, leaflet and ventricle were used to measure annulus, leaflet, prolapse and tethering values, and anterior papillary muscle (APM) angle. TR grade, ventricle size, function and shape were assessed with 2DE.
Results
Patients requiring TVR had greater total leaflet prolapse, larger TV annular and leaflet areas, and flatter annulus, with no difference in tethering, coaptation index or APM angle. HLHS patients with successful TVR at follow-up (58%) was associated with preoperative total leaflet prolapse (especially posterior). Unsuccessful repair was associated with preoperative tethering of septal leaflet. TVR in HLHS patients caused a reduction of total annulus and leaflets size, reduced prolapse and tethering of posterior leaflet, but did not affect anterior leaflet prolapse or septal leaflet tethering.
Conclusion
Features associated with TVR include a flattened and dilated TV annulus with leaflet prolapse. The additional presence of a tethered septal leaflet prior to TVR is associated with significant post-operative TR. Current surgical techniques, predominantly posterior annuloplasty and commissuroplasty, adequately address annulus size and posterior leaflet pathology, but not septal leaflet tethering. Individualized and innovative surgical techniques are vital to improve surgical repair success.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 16 Jun 2021; epub ahead of print
Shigemitsu S, Mah K, Thompson RB, Grenier J, ... Khoo NS, Colen T
J Am Soc Echocardiogr: 16 Jun 2021; epub ahead of print | PMID: 34147648
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Impact:
Abstract

Echocardiographic versus Angiographic Measurement of the Patent Ductus Arteriosus in Extremely Low Birth Weight Infants and the Utility of Echo Guidance for Transcatheter Closure.

Paudel G, Johnson JN, Philip R, Tailor N, ... Waller BR, Sathanandam S
Background
Transthoracic echocardiography (TTE) is increasingly utilized for guiding transcatheter closure of patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. The objectives of this study were to compare PDA size measurements by TTE with angiographic measurements and to describe TTE techniques used in guiding transcatheter PDA closure (TCPC) in ELBW infants.
Methods
One hundred twenty-five consecutive ELBW infants (gestational age < 27 weeks, birth weight < 1 kg) who underwent TCPC before 8 weeks of age under TTE guidance were included. Patent ductus arteriosus sizes were measured from the procedural TTE and angiograms retrospectively by blinded observers. The TTE PDA diameters at the aortic (ED1) and pulmonary end (ED2) were compared with the corresponding angiographic diameters (CD1 and CD2). The TTE PDA lengths, obtained by two techniques (EL1, a straight line between ED1 and ED2; and EL2, a curvilinear line along the PDA), were compared with the PDA length by angiography (CL). Transthoracic echocardiography was used to guide accurate device positioning within the PDA.
Results
The procedure weight was 600-1,460 g. The TTE and angiographic PDA diameters were comparable (mean ED1 vs CD1 = 4.5 ± 0.68 vs 4.4 ± 0.85 mm, P = .26; and mean ED2 vs CD2 = 3.1 ± 0.72 vs 3.2 ± 0.94 mm, P = .14). The angiographic length was underestimated by EL1 by 2.6 ± 1.6 mm (P < .0001), while EL2 estimated it better (mean EL2 vs CL = 11.0 ± 1.83 vs 10.8 ± 2.15 mm; P = .40). Transcatheter PDA closure was successful in 100% of the cases using TTE guidance. There were no intraprocedural complications.
Conclusions
Transthoracic echocardiography guidance during TCPC in ELBW infants eliminates the need for aortograms via femoral arterial access, preventing the complications associated with it. Transthoracic echocardiography PDA measurements are comparable to angiographic measurements, thereby assisting in appropriate device size selection.

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

J Am Soc Echocardiogr: 14 Jun 2021; epub ahead of print
Paudel G, Johnson JN, Philip R, Tailor N, ... Waller BR, Sathanandam S
J Am Soc Echocardiogr: 14 Jun 2021; epub ahead of print | PMID: 34139301
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Abstract

Vascularized Carotid Atherosclerotic Plaque Models for the Validation of Novel Methods of Quantifying Intraplaque Neovascularization.

Boswell-Patterson CA, Hétu MF, Kearney A, Pang SC, ... Zhou J, Johri AM
Background
Intraplaque neovascularization (IPN) in advanced lesions of the carotid artery has been linked to plaque progression and risk of rupture. Quantitative measurement of IPN may provide a more powerful tool for the detection of such \"vulnerable\" plaque than the current visual scoring method. The aim of this study was to develop a phantom platform of a neovascularized atherosclerotic plaque within a carotid artery to assess new methods of quantifying IPN.
Methods
Ninety-two synthetic plaque models with various IPN architectures representing different ranges of IPN scoring were created and assessed using contrast-enhanced ultrasound. Intraplaque neovascularization volume was calculated from contrast infiltration in B mode. The plaque models were used to develop a testing platform for IPN quantification. A neovascularized enhancement ratio (NER) was calculated using commercially available software. The plaque model NERs were then compared to human plaque NERs (n = 42) to assess score relationship. Parametric mapping of dynamic intensity over time was used to differentiate IPN from calcified plaque regions.
Results
A positive correlation between NER and IPN volume (rho = 0.45; P < .0001) was found in the plaque models. Enhancement of certain plaque model types showed that they resembled human plaques, with visual grade scores of 0 (NER mean difference = 1.05 ± SE 2.45; P = .67), 1 (NER mean difference = 0.22 ± SE 3.26; P = .95), and 2 (NER mean difference = -0.84 ± SE 3.33; P = .80). An optimal cutoff for NER (0.355) identified grade 2 human plaques with a sensitivity of 95% and specificity of 91%.
Conclusions
We developed a carotid artery model of neovascularized plaque and established a quantitative method for IPN using commercially available technology. We also developed an analysis method to quantify IPN in calcified plaques. This novel tool has the potential to improve clinical identification of vulnerable plaques, providing objective measures of IPN for cardiovascular risk assessment.

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

J Am Soc Echocardiogr: 11 Jun 2021; epub ahead of print
Boswell-Patterson CA, Hétu MF, Kearney A, Pang SC, ... Zhou J, Johri AM
J Am Soc Echocardiogr: 11 Jun 2021; epub ahead of print | PMID: 34129920
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Impact:
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). The aim of this study was to test the hypothesis that combining SE with carotid CEUS in patients with known or suspected CAD might provide incremental prognostic value beyond clinical risk factors and either test alone for the occurrence of cardiovascular events.
Methods
One hundred eighty-five patients (mean age, 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 (CVEs) including cardiac death, myocardial infarction, unstable angina, and transient ischemic attack or stroke. A subset of patients (n = 27) underwent carotid magnetic resonance imaging within 1 month of CEUS; carotid plaque was assessed for lipid-rich necrotic core, loose matrix, and presence of intraplaque hemorrhage.
Results
Sixty-nine patients had abnormal findings on SE. IPN was identified in 112 patients; 52 patients had IPN localized to plaque shoulder (IPNS). Plaques with IPNS had larger lipid-rich necrotic cores and were more likely to have intraplaque hemorrhage. During follow-up (median, 31 months), 26 CVEs occurred. Multivariate Cox proportional-hazard analysis showed IPN and IPNS to be predictors of CVEs (hazard ratios, 3.34 [95% CI, 1.25-8.93; P = .02] and 4.88 [95% CI, 1.77-13.49; P = .002], respectively). The presence of IPNS increased the likelihood of CVEs beyond SE and history of CAD (χ2 = 9.0, P = .02).
Conclusions
Carotid IPN detected by CEUS and localized to plaque shoulder was an independent predictor of CVEs in patients referred for SE.

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

J Am Soc Echocardiogr: 30 May 2021; 34:614-624
Huang R, DeMarco JK, Ota H, Macedo TA, ... Pellikka PA, Mulvagh SL
J Am Soc Echocardiogr: 30 May 2021; 34:614-624 | PMID: 33387609
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Impact:
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
The diagnosis of coronary artery abnormalities (CAA), including dilation and aneurysm, in patients with Kawasaki disease is paramount to treatment planning. CAA are defined using various standards, which makes diagnosis difficult. The aims of this study were to determine the variability of CAA prevalence according to existing guidelines and Z score formulas and to examine the discrepancies in widely used Z score formulas.
Methods
Using data from a Korean national survey on Kawasaki disease, 6,889 patients were included and analyzed. The overall prevalence of CAA and the prevalence for subgroups were compared on the basis of aneurysm severity, age, and body surface area. Finally, discrepancies among five Z score formulas were evaluated by comparing two of the formulas in pairs.
Results
According to the Japanese criteria, the prevalence of CAA was 18%. According to the American Heart Association criteria, the prevalence of dilation or aneurysm was about 21% to 42%, and that of aneurysm of the left anterior descending artery or right coronary artery was about 8% to 27%. The prevalence of CAA and that of left anterior descending or right coronary artery aneurysm was significantly different, with discrepancies between the Japanese and AHA Z score criteria, as well as among the five Z score formulas. Additionally, misclassification of aneurysm severity was observed for each criterion or Z score formula. There was significant variation among calculated Z scores. The more extreme the Z score values, the more discrepancy was observed.
Conclusions
Different guidelines and Z score formulas yield significantly different prevalence rates and classifications of CAA. In addition, more discrepancies were observed with higher Z score values. As CAA or aneurysm severity could be changed by guidelines or Z score formulas, they should be chosen carefully, and when a particular formula is chosen, consistency is needed.

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

J Am Soc Echocardiogr: 30 May 2021; 34:662-672.e3
Kim SH, Kim JY, Kim GB, Yu JJ, Choi JW
J Am Soc Echocardiogr: 30 May 2021; 34:662-672.e3 | PMID: 33422668
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Impact:
Abstract

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

Yin LX, Ma CY, Wang S, Wang YH, ... Ren WD, Study Investigators
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 a lack of reference values has precluded its widespread use in clinical practice. The aims of this study were 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 men [38%]; age range, 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). Basic clinical parameters and carotid PWV at the beginning of systole (BS) and at end-systole (ES) were measured using ultrafast ultrasound imaging techniques.
Results
PWV at both BS and ES was significantly higher in the left carotid artery than in the right carotid artery. PWV at BS was significantly higher in men than in women; however, no significant difference was noted in PWV at ES between men and women. Multiple linear regression analyses revealed that age, BP, and BMI were independently correlated with PWV at both BS and ES. PWV at BS and ES progressively increased with increases in age, BP, and BMI. Furthermore, 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 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 May 2021; 34:629-641
Yin LX, Ma CY, Wang S, Wang YH, ... Ren WD, Study Investigators
J Am Soc Echocardiogr: 30 May 2021; 34:629-641 | PMID: 33422666
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Impact:
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 (1) to compare the TA size and function in AF patients versus healthy subjects; (2) to identify the determinants of TA remodeling in patients with AF and FTR; and (3) 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 < .0001) but only mild correlation with RV end-diastolic volume and sex (r = 0.3405, P = .0019; r = 0.2914, P = .0075). At multivariable analysis, only RAVmin was independently associated with TA area in AF patients (r = 0.665, P < .0001). The 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. The RAVmin and TA area were directly correlated to FTR severity.

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

J Am Soc Echocardiogr: 30 May 2021; 34:585-594.e1
Guta AC, Badano LP, Tomaselli M, Mihalcea D, ... Parati G, Muraru D
J Am Soc Echocardiogr: 30 May 2021; 34:585-594.e1 | PMID: 33440232
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Impact:
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 offer added value for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair is yet unknown, and few data exist regarding the safety and feasibility of this novel technology.
Methods
The aim of this single-center study was to test and validate a FI protocol for intraprocedural monitoring of transcatheter edge-to-edge mitral valve repair and assess its clinical usefulness. Eighty patients underwent MitraClip implantation using FI guidance (FI+) for either degenerative (35%) or functional (65%) mitral regurgitation and were compared with the last 80 patients before FI introduction, treated using conventional echocardiography and fluoroscopic monitoring (FI-).
Results
The number of patients treated for functional and degenerative mitral regurgitation was similar between the FI+ and FI- groups, as well as the number of devices implanted (1.51 ± 0.5 vs 1.58 ± 0.6, P = .46). The 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 = .003), but not kerma area product (91.5 ± 74.1 vs 108.8 ± 105.0 Gy · cm2, P = .23) or procedural time (92.2 ± 36.1 vs 103.1 ± 42.7 min, P = .086). After adjusting for confounding factors (MitraClip XT device and complex anatomy), FI reduced fluoroscopy time (coefficient = -10.4 min; 95% CI, -18.03 to -2.82; P = .007) and improved procedural success at the end of the procedure (odds ratio, 2.87; 95% CI, 1.00 to 8.24; P = .049) and discharge (odds ratio, 2.24; 95% CI, 1.04 to 4.80; P = .039). Rates of periprocedural complications were similar in both groups (8.9% vs 13.0%, P = .40).
Conclusions
The authors describe the systematic use of an FI protocol for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair, demonstrating a reduction in fluoroscopy time and an improvement in procedural success in a population with a high prevalence of challenging mitral anatomy for percutaneous repair.

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

J Am Soc Echocardiogr: 30 May 2021; 34:604-613
Melillo F, Fisicaro A, Stella S, Ancona F, ... Colombo A, Agricola E
J Am Soc Echocardiogr: 30 May 2021; 34:604-613 | PMID: 33453367
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Impact:
Abstract

Cardiovascular Dysfunction in Children Exposed to Preeclampsia During Fetal Life.

Hoodbhoy Z, Mohammed N, Rozi S, Aslam N, ... Chowdhury D, Hasan BS
Background
Keeping in view the developmental origin of health and disease hypothesis, the aim of this study was to assess differences in cardiac and vascular structure and function in children exposed to preeclampsia in utero compared with those of normotensive mothers. The hypothesis under investigation was that children exposed to preeclampsia would have altered cardiac and vascular structure and function compared with the unexposed group.
Methods
This was a retrospective cohort study that included children 2 to 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 echocardiography and carotid intima-media thickness and pulse-wave velocity were determined. Multivariate linear regression was used to compare preeclampsia-exposed and nonexposed groups. Subgroup analysis to assess differences between early- and late-onset preeclampsia was also performed.
Results
Forty-one percent of mothers (n = 33) had early-onset preeclampsia. Children in the exposed group had a significantly higher prevalence of stage 1 systolic and diastolic hypertension (22% [n = 18] and 35% [n = 18], respectively) compared with the unexposed group (9% [n = 7] and 19% [n = 15], respectively; P = .01). Children in the exposed group also had higher pulse-wave velocity compared with those in the unexposed group (0.42 ± 0.1 vs 0.39 ± 0.1, P = .03). Subgroup analysis revealed that changes in blood pressure and pulse-wave velocity were determined primarily 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 vascular function in children aged 2 to 10 years, related primarily to early-onset disease. Routine blood pressure screening should be recommended for such children.

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

J Am Soc Echocardiogr: 30 May 2021; 34:653-661
Hoodbhoy Z, Mohammed N, Rozi S, Aslam N, ... Chowdhury D, Hasan BS
J Am Soc Echocardiogr: 30 May 2021; 34:653-661 | PMID: 33453366
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Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 30 May 2021; 34:571-581
MacKay EJ, Zhang B, Heng S, Ye T, ... Desai ND, Groeneveld PW
J Am Soc Echocardiogr: 30 May 2021; 34:571-581 | PMID: 33508414
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Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 30 May 2021; 34:595-603.e2
Oguz D, Padang R, Rashedi N, Pislaru SV, ... Rihal CS, Thaden JJ
J Am Soc Echocardiogr: 30 May 2021; 34:595-603.e2 | PMID: 33524491
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Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 30 May 2021; 34:676-689
Protsyk V, Meineri M, Kitamura M, Flo Forner A, ... Abdel-Wahab M, Ender JK
J Am Soc Echocardiogr: 30 May 2021; 34:676-689 | PMID: 33675944
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Impact:
Abstract

Cardiac Damage Staging Classification Predicts Prognosis in All the Major Subtypes of Severe Aortic Stenosis: Insights from the National Echo Database Australia.

Snir AD, Ng MK, Strange G, Playford D, ... Celermajer DS, National Echo Database of Australia
Background
There are currently no established prognostic models for \"low-gradient\" severe aortic stenosis (AS), including those with low-flow, low-gradient (LFLG) or normal-flow, low-gradient (NFLG) severe AS. The \"cardiac damage staging classification\" has been validated as a clinically useful prognostic tool for high-gradient severe AS but not yet for these other common subtypes of severe AS, LFLG and NFLG.
Methods
The authors analyzed data from the National Echo Database of Australia, a large national, multicenter registry with individual data linkage to mortality. Of 192,060 adults (mean age, 62.8 ± 17.8 years) with comprehensive ultrasound profiling of the native aortic valve studied between 2000 and 2019, 12,013 (6.3%) had severe AS. On the basis of standard echocardiographic parameters, 5,601 patients with high-gradient, 611 with classical and 959 with paradoxical LFLG, and 911 with NFLG severe AS were identified. Mean follow-up was 88 ± 45 months. All-cause and cardiovascular-related mortality were assessed for each group on an adjusted basis (age and sex) and analyzed by cardiac damage stage.
Results
Patients with LFLG AS had greater associated cardiac damage at diagnosis (stages 3 and 4 in 34% of those with classical LFLG, 22.5% of those with paradoxical LFLG, 15.5% of those with NFLG, and 14% of those with high-gradient AS; P < .001). For all four major subtypes of severe AS, there was a progressive increase in 1- and 5-year mortality with increasing cardiac damage score. For example, for paradoxical LFLG severe AS, compared with stage 0 patients, adjusted 1-year all-cause mortality was 22% higher in stage 1 patients, 55% higher in stage 2 patients (P = .095), and 155% higher in stage 3 and 4 patients (P < .001). Among patients with classical LFLG severe AS, compared with stage 1 patients, adjusted 1-year all-cause mortality was 55% higher in stage 2 patients (P = .018) and 100% higher in stage 3 and 4 patients (P < .001).
Conclusions
Regardless of severe AS subtype, increasing severity denoted by the cardiac damage staging classification is strongly associated with increasing mortality risk.

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

J Am Soc Echocardiogr: 30 May 2021; epub ahead of print
Snir AD, Ng MK, Strange G, Playford D, ... Celermajer DS, National Echo Database of Australia
J Am Soc Echocardiogr: 30 May 2021; epub ahead of print | PMID: 34082021
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Impact:
Abstract

The Impact of Vendor-Specific Ultrasound Beam-Forming and Processing Techniques on the Visualization of In Vitro Experimental \"Scar\": Implications for Myocardial Scar Imaging Using Two-Dimensional and Three-Dimensional Echocardiography.

Papachristidis A, Queirós S, Theodoropoulos KC, D\'hooge J, ... Murgatroyd FD, Monaghan MJ
Background
Myocardial scar appears brighter compared with normal myocardium on echocardiography because of differences in tissue characteristics. The aim of this study was to test how different ultrasound pulse characteristics affect the brightness contrast (i.e., contrast ratio [CR]) between tissues of different acoustic properties, as well as the accuracy of assessing tissue volume.
Methods
An experimental in vitro \"scar\" model was created using overheated and raw pieces of commercially available bovine muscle. Two-dimensional and three-dimensional ultrasound scanning of the model was performed using combinations of ultrasound pulse characteristics: ultrasound frequency, harmonics, pulse amplitude, steady pulse (SP) emission, power modulation (PM), and pulse inversion modalities.
Results
On both two-dimensional and three-dimensional imaging, the CR between the \"scar\" and its adjacent tissue was higher when PM was used. PM, as well as SP ultrasound imaging, provided good \"scar\" volume quantification. When tested on 10 \"scars\" of different size and shape, PM resulted in lower bias (-9.7 vs 54.2 mm3) and narrower limits of agreement (-168.6 to 149.2 mm3 vs -296.0 to 404.4 mm3, P = .03). The interobserver variability for \"scar\" volume was better with PM (intraclass correlation coefficient = 0.901 vs 0.815). Two-dimensional and three-dimensional echocardiography with PM and SP was performed on 15 individuals with myocardial scar secondary to infarction. The CR was higher on PM imaging. Using cardiac magnetic resonance as a reference, quantification of myocardial scar volume showed better agreement when PM was used (bias, -645 mm3; limits of agreement, -3,158 to 1,868 mm3) as opposed to SP (bias, -1,138 mm3; limits of agreement, -5,510 to 3,233 mm3).
Conclusions
The PM modality increased the CR between tissues with different acoustic properties in an experimental in vitro \"scar\" model while allowing accurate quantification of \"scar\" volume. By applying the in vitro findings to humans, PM resulted in higher CR between scarred and healthy myocardium, providing better scar volume quantification than SP compared with cardiac magnetic resonance.

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

J Am Soc Echocardiogr: 30 May 2021; epub ahead of print
Papachristidis A, Queirós S, Theodoropoulos KC, D'hooge J, ... Murgatroyd FD, Monaghan MJ
J Am Soc Echocardiogr: 30 May 2021; epub ahead of print | PMID: 34082020
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Impact:
Abstract

Percutaneous Edge-to-Edge Mitral Valve Repair: Beyond the Left Heart.

Italia L, Adamo M, Lupi L, Scodro M, Curello S, Metra M
Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) are known to be associated with adverse outcomes in patients undergoing percutaneous mitral valve repair (PMVR). Although the effect of PMVR on left ventricular function is well known, data on the response of the right ventricle to PMVR, and its impact on prognosis, are limited. In this review the authors summarize available data regarding the prognostic role of RV function and TR in PMVR recipients and the possible effects of PMVR on the right heart. Preprocedural tricuspid annular plane systolic excursion < 15 mm, tricuspid annular tissue Doppler S\' velocity < 9.5 cm/sec, and moderate or severe TR are reported as predictors of adverse outcome after PMVR. Therefore, they should be carefully evaluated for patient selection. Moreover, emerging data show that the benefit of PMVR may go beyond the left heart, leading to an improvement in RV function and a reduction in TR severity. Among PMVR recipients, improvement in RV function and reduction of TR degree are observed mainly in patients with RV dysfunction at baseline. On the other hand, high postprocedural transmitral pressure gradients seem to be associated with lack of RV reverse remodeling. Timing of mitral intervention with respect to RV impairment and predictors of RV reverse remodeling after PMVR are unknown. Further studies are needed to fill these gaps in evidence.

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

J Am Soc Echocardiogr: 26 May 2021; epub ahead of print
Italia L, Adamo M, Lupi L, Scodro M, Curello S, Metra M
J Am Soc Echocardiogr: 26 May 2021; epub ahead of print | PMID: 34052316
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Impact:
Abstract

Normal Values of Cardiac Output and Stroke Volume According to Measurement Technique, Age, Sex, and Ethnicity: Results of the World Alliance of Societies of Echocardiography Study.

Patel HN, Miyoshi T, Addetia K, Henry MP, ... Lang RM, WASE Investigators
Background
Assessment of cardiac output (CO) and stroke volume (SV) is essential to understand cardiac function and hemodynamics. These parameters can be examined using three echocardiographic techniques (pulsed-wave Doppler, two-dimensional [2D], and three-dimensional [3D]). Whether these methods can be used interchangeably is unclear. The influence of age, sex, and ethnicity on CO and SV has also not been examined in depth. In this report from the World Alliance of Societies of Echocardiography Normal Values Study, the authors compare CO and SV in healthy adults according to age, sex, ethnicity, and measurement techniques.
Methods
A total of 1,450 adult subjects (53% men) free of heart, lung, and kidney disease were prospectively enrolled in 15 countries, with even distributions among age groups and sex. Subjects were divided into three age groups (young, 18-40 years; middle aged, 41-65 years; and old, >65 years) and three main racial groups (whites, blacks, and Asians). CO and SV were indexed (cardiac index [CI] and SV index [SVI], respectively) to body surface area and height and measured using three echocardiographic methods: Doppler, 2D, and 3D. Images were analyzed at two core laboratories (one each for 2D and 3D).
Results
CI and SVI were significantly lower by 2D compared with both Doppler and 3D methods in both sexes. SVI was significantly lower in women than men by all three methods, while CI differed only by 2D. SVI decreased with aging by all three techniques, whereas CI declined only with 2D and 3D. CO and SV were smallest in Asians and largest in whites, and the differences persisted after normalization for body surface area.
Conclusions
The present results provide normal reference values for CO and SV, which differ by age, sex, and race. Furthermore, CI and SVI measurements by the different echocardiographic techniques are not interchangeable. All these factors need to be taken into account when evaluating cardiac function and hemodynamics in individual patients.

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

J Am Soc Echocardiogr: 24 May 2021; epub ahead of print
Patel HN, Miyoshi T, Addetia K, Henry MP, ... Lang RM, WASE Investigators
J Am Soc Echocardiogr: 24 May 2021; epub ahead of print | PMID: 34044105
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Impact:
Abstract

Echocardiographic Correlates of In-Hospital Death in Patients with Acute COVID-19 Infection: The World Alliance Societies of Echocardiography (WASE-COVID) Study.

Karagodin I, Carvalho Singulane C, Woodward GM, Xie M, ... Asch FM, WASE-COVID Investigators
Background
The novel severe acute respiratory syndrome coronavirus-2 virus, which has led to the global coronavirus disease-2019 (COVID-19) pandemic is known to adversely affect the cardiovascular system through multiple mechanisms. In this international, multicenter study conducted by the World Alliance Societies of Echocardiography, we aim to determine the clinical and echocardiographic phenotype of acute cardiac disease in COVID-19 patients, to explore phenotypic differences in different geographic regions across the world, and to identify parameters associated with in-hospital mortality.
Methods
We studied 870 patients with acute COVID-19 infection from 13 medical centers in four world regions (Asia, Europe, United States, Latin America) who had undergone transthoracic echocardiograms. Clinical and laboratory data were collected, including patient outcomes. Anonymized echocardiograms were analyzed with automated, machine learning-derived algorithms to calculate left ventricular (LV) volumes, ejection fraction, and LV longitudinal strain (LS). Right-sided echocardiographic parameters that were measured included right ventricular (RV) LS, RV free-wall strain (FWS), and RV basal diameter. Multivariate regression analysis was performed to identify clinical and echocardiographic parameters associated with in-hospital mortality.
Results
Significant regional differences were noted in terms of patient comorbidities, severity of illness, clinical biomarkers, and LV and RV echocardiographic metrics. Overall in-hospital mortality was 21.6%. Parameters associated with mortality in a multivariate analysis were age (odds ratio [OR] = 1.12 [1.05, 1.22], P = .003), previous lung disease (OR = 7.32 [1.56, 42.2], P = .015), LVLS (OR = 1.18 [1.05, 1.36], P = .012), lactic dehydrogenase (OR = 6.17 [1.74, 28.7], P = .009), and RVFWS (OR = 1.14 [1.04, 1.26], P = .007).
Conclusions
Left ventricular dysfunction is noted in approximately 20% and RV dysfunction in approximately 30% of patients with acute COVID-19 illness and portend a poor prognosis. Age at presentation, previous lung disease, lactic dehydrogenase, LVLS, and RVFWS were independently associated with in-hospital mortality. Regional differences in cardiac phenotype highlight the significant differences in patient acuity as well as echocardiographic utilization in different parts of the world.

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

J Am Soc Echocardiogr: 20 May 2021; epub ahead of print
Karagodin I, Carvalho Singulane C, Woodward GM, Xie M, ... Asch FM, WASE-COVID Investigators
J Am Soc Echocardiogr: 20 May 2021; epub ahead of print | PMID: 34023454
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Impact:
Abstract

A Systematic Review of Scaling Left Atrial Size: Are Alternative Indexation Methods Required for an Increasingly Obese Population?

Jeyaprakash P, Moussad A, Pathan S, Sivapathan S, ... Negishi K, Pathan F
Background
Left atrial (LA) size indexed to body surface area (BSA) is a clinically important marker of cardiovascular prognosis. However, indexation using a scaling variable such as BSA has inherent flaws, particularly in an obese population. The aim of this study was to determine whether alternative indexation methods may more accurately scale for LA size.
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to execute a structured search of medical databases, to identify articles discussing alternative methods of LA indexation in echocardiography. Articles that stratified indexed LA size by obesity class were also included. Two independent reviewers identified relevant articles and extracted baseline characteristics, alternative indexation methods, scaling variables, obesity class characteristics, and correlation coefficients.
Results
A total of 3,804 articles were found in the database search after removing duplicates. After abstract and full-text screening, 13 relevant articles were identified. Twelve studies used alternative methods of LA indexation, of which nine reported allometric indices. Seven of the included studies reported LA size by obesity class, of which six reported alternative indices. Correlation coefficients plotted for indexed LA size against absolute measured LA size showed that allometric indices (specifically to height) were more likely to maintain proportionality to body size compared with isometric indices such as BSA. Allometric indices were less likely to overcorrect for body size compared with isometric indices.
Conclusions
Compared with isometric indexation to BSA, allometric indexation (specifically to height) improves scaling of LA volumes to maintain proportionality and avoid overcorrection for body size.

Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 19 May 2021; epub ahead of print
Jeyaprakash P, Moussad A, Pathan S, Sivapathan S, ... Negishi K, Pathan F
J Am Soc Echocardiogr: 19 May 2021; epub ahead of print | PMID: 34023453
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Impact:
Abstract

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

Medvedofsky D, Milhorini Pio S, Weissman NJ, Namazi F, ... Asch FM, COAPT Investigators
Background
Left ventricular (LV) global longitudinal strain (GLS) is a sensitive marker of LV function and may help identify patients with heart failure (HF) and secondary mitral regurgitation who would have a better prognosis and are more likely to benefit from edge-to-edge transcatheter mitral valve repair with the MitraClip. The aim of this study was to assess the prognostic utility of baseline LV GLS during 2-year follow-up of patients with HF with secondary mitral regurgitation enrolled in the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation trial.
Methods
Patients with symptomatic HF with moderate to severe or severe secondary mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT) were randomized to transcatheter mitral valve repair plus GDMT or GDMT alone. Speckle-tracking-derived LV GLS from baseline echocardiograms was obtained in 565 patients and categorized in tertiles. Death and HF hospitalization at 2-year follow-up were the principal outcomes of interest.
Results
Patients with better baseline LV GLS had higher blood pressure, greater LV ejection fraction and stroke volume, lower levels of B-type natriuretic peptide, and smaller LV size. No significant difference in outcomes at 2-year follow-up were noted according to LV GLS. However, the rate of death or HF hospitalization between 10 and 24 months was lower in patients with better LV GLS (P = .03), with no differences before 10 months. There was no interaction between GLS tertile and treatment group with respect to 2-year clinical outcomes.
Conclusions
Baseline LV GLS did not predict death or HF hospitalization throughout 2-year follow-up, but it did predict outcomes after 10 months. The benefit of transcatheter mitral valve repair over GDMT alone was consistent in all subgroups irrespective of baseline LV GLS.

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

J Am Soc Echocardiogr: 07 May 2021; epub ahead of print
Medvedofsky D, Milhorini Pio S, Weissman NJ, Namazi F, ... Asch FM, COAPT Investigators
J Am Soc Echocardiogr: 07 May 2021; epub ahead of print | PMID: 33845158
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Impact:
Abstract

Reference Ranges for Pulsed-Wave Doppler of the Fetal Cardiac Inflow and Outflow Tracts from 13 to 36 Weeks\' Gestation.

Zidere V, Vigneswaran TV, Syngelaki A, Charakida M, ... Simpson JM, Akolekar R
Background
Doppler assessment of ventricular filling and outflow tract velocities is an integral part of fetal echocardiography, to assess diastolic function, systolic function, and outflow tract obstruction. There is a paucity of prospective data from a large sample of normal fetuses in the published literature. The authors report reference ranges for pulsed-wave Doppler flow of the mitral valve, tricuspid valve, aortic valve, and pulmonary valve, as well as heart rate, in a large number of fetuses prospectively examined at a single tertiary fetal cardiology center.
Methods
The study population comprised 7,885 fetuses at 13 to 36 weeks\' gestation with no detectable abnormalities from pregnancies resulting in normal live births. Prospective pulsed-wave Doppler blood flow measurements were taken of the mitral, tricuspid, aortic, and pulmonary valves. The fetal heart rate was recorded at the time of each assessment. Regression analysis, with polynomial terms to assess for linear and nonlinear contributors, was used to establish the relationship between each measurement and gestational age.
Results
The measurement for each cardiac Doppler measurement was expressed as a Z score (difference between observed and expected values divided by the fitted SD corrected for gestational age) and percentile. Analysis included calculation of gestation-specific SDs. Regression equations are provided for the cardiac inflow and outflow tracts.
Conclusions
This study establishes reference ranges for fetal cardiac Doppler measurements and heart rate between 13 to 36 weeks\' gestation that may be useful in clinical practice.

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

J Am Soc Echocardiogr: 02 May 2021; epub ahead of print
Zidere V, Vigneswaran TV, Syngelaki A, Charakida M, ... Simpson JM, Akolekar R
J Am Soc Echocardiogr: 02 May 2021; epub ahead of print | PMID: 33957251
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Impact:
Abstract

Echocardiographic Indicators Associated with Adverse Clinical Course and Cardiac Sequelae in Multisystem Inflammatory Syndrome in Children with Coronavirus Disease 2019.

Sanil Y, Misra A, Safa R, Blake JM, ... Aggarwal S, Singh G
Background
Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 causes significant cardiovascular involvement, which can be a determinant of clinical course and outcome. The aim of this study was to investigate whether echocardiographic measures of ventricular function were independently associated with adverse clinical course and cardiac sequelae in patients with MIS-C.
Methods
In a longitudinal observational study of 54 patients with MIS-C (mean age, 6.8 ± 4.4 years; 46% male; 56% African American), measures of ventricular function and morphometry at initial presentation, predischarge, and at a median of 3- and 10-week follow-up were retrospectively analyzed and were compared with those in 108 age- and gender-matched normal control subjects. The magnitude of strain is expressed as an absolute value. Risk stratification for adverse clinical course and outcomes were analyzed among the tertiles of clinical and echocardiographic data using analysis of variance and univariate and multivariate regression.
Results
Median left ventricular apical four-chamber peak longitudinal strain (LVA4LS) and left ventricular global longitudinal strain (LVGLS) at initial presentation were significantly decreased in patients with MIS-C compared with the normal cohort (16.2% and 15.1% vs 22.3% and 22.0%, respectively, P < .01). Patients in the lowest LVA4LS tertile (<13%) had significantly higher C-reactive protein and high-sensitivity troponin, need for intensive care, and need for mechanical life support as well as longer hospital length of stay compared with those in the highest tertile (>18.5%; P < .01). Initial LVA4LS and LVGLS were normal in 13 of 54 and 10 of 39 patients, respectively. There was no mortality. In multivariate regression, only LVA4LS was associated with both the need for intensive care and length of stay. At median 10-week follow-up to date, seven of 36 patients (19%) and six of 25 patients (24%) had abnormal LVA4LS and LVGLS, respectively. Initial LVA4LS < 16.2% indicated abnormal LVA4LS at follow-up with 100% sensitivity.
Conclusion
Impaired LVGLS and LVA4LS at initial presentation independently indicate a higher risk for adverse acute clinical course and persistent subclinical left ventricular dysfunction at 10-week follow-up, suggesting that they could be applied to identify higher risk children with MIS-C.

Published by Elsevier Inc.

J Am Soc Echocardiogr: 02 May 2021; epub ahead of print
Sanil Y, Misra A, Safa R, Blake JM, ... Aggarwal S, Singh G
J Am Soc Echocardiogr: 02 May 2021; epub ahead of print | PMID: 33957250
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Impact:
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, which affects the right ventricle and to a lesser extent the left ventricle. Hypoxic exposure induces an additional increase in right ventricular (RV) afterload. Therefore, exercise in hypoxia may differently affect both ventricles. The aim of this study was to investigate the acute effects of a bout of high-intensity exercise under hypoxia versus normoxia in healthy individuals on right- and left-sided cardiac function and mechanics.
Methods
Twenty-one healthy individuals (mean age, 22.2 ± 0.6 years; 14 men) performed 45-min high-intensity running exercise under hypoxia (fraction of inspired oxygen 14.5%) and normoxia (fraction of inspired oxygen 20.9%) in a randomized order. Pre- and post-exercise echocardiography, at rest and during low-to-moderate intensity recumbent exercise (\"stress\"), was performed to assess RV and left ventricular (LV) cardiac function and mechanics. RV structure, function, and mechanics were assessed using conventional two-dimensional, Doppler, tissue Doppler, speckle-tracking echocardiographic, and novel strain-area loops.
Results
Indices of RV systolic function (RV fractional area change, Tricuspid annular plane systolic excursion, RV s\', and RV free wall strain) and LV function (LV ejection fraction and LV global longitudinal strain) were significantly reduced after high-intensity running exercise (P < .01). These exercise-induced changes were more pronounced when echocardiography was examined during stress compared with baseline. These responses in RV and LV indices were not altered under hypoxia (P > .05).
Conclusions
There was no impact of hypoxia on the magnitude of exercise-induced cardiac fatigue in the right and left ventricles after a 45-min bout of high-intensity exercise. This finding suggests that any potential increase in loading conditions does not automatically exacerbate exercise-induced cardiac fatigue in this setting.

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:511-521
Kleinnibbelink G, van Dijk APJ, Fornasiero A, Speretta GF, ... Thijssen DHJ, Oxborough DL
J Am Soc Echocardiogr: 29 Apr 2021; 34:511-521 | PMID: 33333146
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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 patients with hypoplastic left heart syndrome (HLHS) require tricuspid valve (TV) repair. The location of tricuspid regurgitation (TR) is important in determining the type of repair performed. Studies using three-dimensional echocardiography (3DE) have reported a high incidence of error on two-dimensional echocardiography (2DE) for the identification of TV leaflets. The aim of this study was to compare assessment of TR on 3DE and 2DE in patients with HLHS (jet location, TR grade, and reproducibility).
Methods
A retrospective, single-center review was performed. Fifty-six patients with HLHS with available two-dimensional and three-dimensional echocardiograms, and mild or greater TR, were included. TR location, grade, vena contracta area, and TV annular diameter were measured on 2DE and 3DE. Reproducibility was assessed by blinded reviewers.
Results
Three-dimensional echocardiography identified the primary jet location as central (57%) followed by anteroseptal (36%). There was poor agreement between findings on 3DE and 2DE for jet location (κ = 0.05; 95 CI, -0.08 to 0.19). Interobserver reproducibility for location on 3DE was excellent (κ = 0.8), whereas reproducibility for 2DE was poor (κ = 0.32). The most common jet location pre-Norwood and pre-Glenn was central (70%), whereas pre-Fontan and post-Fontan, jet location was central (45%) and anteroseptal (48%). Vena contracta area on 2DE correlated moderately with vena contracta area on 3DE (r = 0.60, P < .0001). TV annular diameters on 2DE and 3DE for lateral (r = 0.85, P < .0001) and anteroposterior (r = 0.74, P = .001) dimensions were strongly correlated.
Conclusions
In children with HLHS, assessment of TR location on 2DE had poor agreement with assessment on 3DE and was poorly reproducible. In contrast, TR jet location on 3DE 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 preoperative identification of TR jet location in patients with HLHS.

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:529-536
Mah K, Khoo NS, Tham E, Yaskina M, ... Smallhorn J, Colen T
J Am Soc Echocardiogr: 29 Apr 2021; 34:529-536 | PMID: 33373699
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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, with a 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. Real-time myocardial contrast echocardiography 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 five patients, two of whom had obstructive CAV and one with mild CAV. Sensitivity and specificity of RTMCE for CAV detection were 60% and 94%, respectively, and diagnostic accuracy was 89%. MBFR assessment 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 vs 3.7 ± 0.8; P < .01). There were no serious adverse events related to RTMCE.
Conclusions
Dobutamine stress RTMCE appears to be safe and feasible for the assessment of CAV in pediatric HT recipients. Further assessment is warranted to determine whether this noninvasive technique could provide a reliable alternative to ICA.

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:503-510
Fine NM, Greenway SC, Mulvagh SL, Huang R, ... Anderson JH, Johnson JN
J Am Soc Echocardiogr: 29 Apr 2021; 34:503-510 | 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, noninvasive identification of patients with heart failure with preserved ejection fraction (HFpEF) with congestion may allow timely tailoring of decongestive therapies. The 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines provide an algorithm to assess for elevated left atrial pressure (LAP); the associations of echocardiographic LAP with clinical status and disease progression in patients with HFpEF are unclear.
Methods
Participants in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF trial were categorized into one of four prespecified guideline-based echocardiographic LAP categories: (1) normal, (2) elevated, (3) atrial fibrillation (AF) at the time of echocardiography, or (4) indeterminate. Associations of echocardiographic LAP categories with baseline exercise capacity, change in exercise capacity, and change in N-terminal pro-B-type natriuretic peptide over 24 weeks were evaluated.
Results
Of 216 participants, 199 underwent mitral inflow Doppler echocardiography for LAP categorization. Participants with elevated echocardiographic LAP (n = 81) or AF (n = 57) were older and had a higher prevalence of kidney dysfunction. Compared with the normal echocardiographic LAP group (n = 28), elevated echocardiographic LAP and AF were each independently associated with a greater reduction in peak oxygen consumption over 24 weeks after adjusting for baseline values and clinical covariates (β for elevated echocardiographic LAP = -1.55 [95% CI, -2.59 to -0.51], P = .004; β for AF = -1.33 [95% CI, -2.49 to -0.17], P = .03). Indeterminate echocardiographic LAP (n = 33) was also independently associated with a reduction in exercise capacity at 24 weeks compared with normal echocardiographic LAP (β = -1.35; 95% CI, -2.51 to -0.19; P = .02). Finally, elevated echocardiographic LAP and AF were significantly associated with increases in N-terminal pro-B-type natriuretic peptide over 24 weeks compared with normal echocardiographic LAP.
Conclusions
In patients with chronic HFpEF, elevated echocardiographic LAP and indeterminate echocardiographic LAP, as defined by contemporary guidelines, and AF were each independently associated with a reduction in exercise capacity compared with normal echocardiographic LAP. These findings suggest the potential utility of noninvasive LAP assessment in patients with HFpEF for tailoring treatments that decrease congestion.

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:455-464
Rethy L, Borlaug BA, Redfield MM, Oh JK, Shah SJ, Patel RB
J Am Soc Echocardiogr: 29 Apr 2021; 34:455-464 | PMID: 33359021
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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 is poorly characterized. The aim of this study was to test the hypothesis 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 9 (n = 4) weeks after Sugen5416 and hypoxia and 12 weeks after PR surgery, myocardial strain and RV pressure were measured and RV pressure-strain loops generated. We further studied RV regional mechanics in 11 patients with PH. Regional myocardial work was calculated as the pressure-strain loop area (mm Hg ∙ %). 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 © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Apr 2021; 34:537-550.e3
Ebata R, Fujioka T, Diab SG, Pieles G, ... Stortz G, Friedberg MK
J Am Soc Echocardiogr: 29 Apr 2021; 34:537-550.e3 | PMID: 33383122
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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. Right ventricular end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RVEF, and 3D RV longitudinal strain (3D-RVLS) of the free wall by 3D-STE and 2D-RVLS of the free wall by 2D-STE, were compared with CMR measurements. Pearson correlation and Bland-Altman analyses were used to assess the intertechnique agreement.
Results
Right ventricular 3D-STE was feasible in 174 patients (89%). Right ventricular 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). Three-dimensional 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 with those with normal RV size, RVEF ≥ 45%, or higher frame rate, respectively. Right ventricular 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 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Apr 2021; 34:472-482
Li Y, Zhang L, Gao Y, Wan X, ... Shi H, Xie M
J Am Soc Echocardiogr: 29 Apr 2021; 34:472-482 | PMID: 33383121
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Abstract

Echocardiographic Findings Associated with Transplantation-Free Survival and Left Ventricular Systolic Function at Midterm 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 with residual disease, but operation in infancy is associated with significant morbidity and mortality. The aim of this study was to evaluate echocardiographic correlates of transplantation-free survival, reintervention, and left ventricular (LV) function in midterm follow-up.
Methods
This retrospective, single-center study included all infants with critical aortic stenosis who underwent Ross by 1 year of age from January 2000 to September 2018. Serial echocardiograms were analyzed for LV ejection fraction (LVEF) and systolic and diastolic longitudinal strain. The primary outcome was mortality or transplantation; secondary outcomes were reintervention and abnormal LVEF (≤55%).
Results
Among 40 infants (30 male [75%]; median age at Ross, 51 days) with median follow-up duration of 3.3 years (interquartile range, 1.0-9.4 years), the primary outcome was met in 11 (28%). Rates of transplantation-free survival was 79%, 77%, and 69% at 1, 5, and 10 years after Ross. Predictors of transplantation or death included neonatal surgery, cross-clamp time, and preoperative left atrial dilatation and lower LVEF. Median freedom from reintervention was 7.1 years after Ross, with no identified associations. LV longitudinal strain improved 1 year after Ross (-21.1 ± 3.8% vs -17.4 ± 5.1%, P = .02), although LVEF did not reach significance. Lower LVEF at 1 year was related to pre-Ross left atrial dilatation (P = .02), abnormal LVEF (P = .04), and lower early diastolic longitudinal strain rate (P = .03). LVEF remained stable 3 years after Ross.
Conclusions
Both transplantation-free survival and normalization of LV function after Ross in infancy are associated with preoperative 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 more precise risk stratification.

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:522-528.e1
Porter A, Yu S, Lowery R, Fifer CG, Lu JC
J Am Soc Echocardiogr: 29 Apr 2021; 34:522-528.e1 | PMID: 33385500
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Abstract

Markers of Elevated Left Ventricular Filling Pressure Are Associated with Increased Mortality in Nonsevere Aortic Stenosis.

Giudicatti LC, Burrows S, Playford D, Strange G, Hillis 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 velocity [E/e\']) and chronic (indexed left atrial volume) markers of left ventricular filling pressure and mortality in patients with nonsevere aortic stenosis (AS), within the National Echo Database Australia cohort, testing the hypothesis that they would reflect the early hemodynamic consequences of AS and be associated with increased mortality in this setting.
Methods
The first record for patients ≥18 years of age showing hemodynamically significant but nonsevere (mild or moderate) AS (mean pressure gradient ≥ 10 to <40 mm Hg and aortic valve area > 1 cm2) was analyzed. Baseline demographics and echocardiographic variables were compared with those among patients without AS (mean pressure gradient < 10 mm Hg). Mortality linkage data were available for all patients.
Results
Of 78,886 patients with aortic valve mean pressure gradients < 40 mm Hg and aortic valve areas > 1 cm2, 13,768 (17%) were identified with nonsevere AS (aortic valve mean pressure gradient 10-40 mm Hg), of whom 57% were men (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, nonsevere AS and indexed left atrial volume > 34 mL/m2 (hazard ratio [HR], 2.29; 95% CI, 2.03-2.58), E/e\' ratio > 14 (HR, 2.27; 95% CI, 2.08-2.49), left ventricular ejection fraction < 50% (HR, 2.82; 95% CI, 2.50-3.19), and tricuspid regurgitation peak velocity > 280 cm/sec (HR, 2.54; 95% CI, 2.30-2.80) were associated with increased mortality hazard at the time of echocardiography. All markers were significant when combined in a multivariate model.
Conclusions
Indices of elevated left ventricular filling pressure are independently associated with death in patients with nonsevere AS. Risk stratification models incorporating these variables may identify patients at risk for complications, warranting closer surveillance and possibly earlier intervention.

Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Apr 2021; 34:465-471
Giudicatti LC, Burrows S, Playford D, Strange G, Hillis G
J Am Soc Echocardiogr: 29 Apr 2021; 34:465-471 | PMID: 33388447
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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 intervals, patients screened for cardiac resynchronization therapy (CRT) are highly heterogeneous, and it remains extremely challenging to predict the impact of CRT devices on left ventricular function and outcomes. The aim of this study was to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular remodeling and prognosis of CRT candidates by the application of machine learning approaches.
Methods
One hundred ninety-three patients with systolic heart failure receiving CRT according to current recommendations were prospectively included in this multicenter study. A combination of the Boruta algorithm and random forest methods was used to identify features predicting both CRT volumetric response and prognosis. Model performance was tested using the area under the receiver operating characteristic curve. The k-medoid method was also applied to identify clusters of phenotypically similar patients.
Results
From 28 clinical, electrocardiographic, and echocardiographic variables, 16 features were predictive of CRT response, and 11 features were predictive of prognosis. Among the predictors of CRT response, eight variables (50%) pertained to right ventricular size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with particularly good prediction of both CRT response (area under the curve, 0.81; 95% CI, 0.74-0.87) and outcomes (area under the curve, 0.84; 95% CI, 0.75-0.93). An unsupervised machine learning approach allowed the identification of two phenogroups of patients who differed significantly in clinical variables and parameters of biventricular size and right ventricular function. The two phenogroups had significantly different prognosis (hazard ratio, 4.70; 95% CI, 2.1-10.0; P < .0001; log-rank P < .0001).
Conclusions
Machine learning can reliably identify clinical and echocardiographic features associated with CRT response and prognosis. The evaluation of both right ventricular size and functional parameters has pivotal importance for the risk stratification of CRT candidates and should be systematically performed in patients undergoing CRT.

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:494-502
Galli E, Le Rolle V, Smiseth OA, Duchenne J, ... Voigt JU, Donal E
J Am Soc Echocardiogr: 29 Apr 2021; 34:494-502 | PMID: 33422667
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Apr 2021; 34:483-493
Gallard A, Bidaut A, Hubert A, Sade E, ... Hernandez A, Donal E
J Am Soc Echocardiogr: 29 Apr 2021; 34:483-493 | PMID: 33524492
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Abstract

Left Atrial Strain and Function in Pediatric Hypertrophic Cardiomyopathy.

Jhaveri S, Komarlu R, Worley S, Shahbah D, Gurumoorthi M, Zahka K
Background
Left atrial (LA) strain and dysfunction are early markers of diastolic dysfunction, associated with poor exercise capacity in adults with hypertrophic cardiomyopathy (HCM). Literature on assessment of LA mechanics in pediatric HCM is lacking. The aim of this study was to assess LA strain and LA function in pediatric patients who have HCM with (phenotype positive [P+]) and without (genotype positive, phenotype negative [G+P-]) ventricular hypertrophy and evaluate their correlation with exercise stress test parameters.
Methods
Seventy-eight children (3-25 years of age) with HCM (P+, n = 46; G+P-, n = 32) and 20 healthy control subjects were retrospectively studied. LA conduit function, reservoir function, and pump function were computed using phasic LA volumetric analysis. LA reservoir strain (LASr) and LA contractile strain were measured using speckle-tracking echocardiography. Exercise test findings within 12 months of echocardiography were recorded.
Results
LA conduit function (36% vs 48%, P < .001) and LA reservoir function (137% vs 180%, P < .001) were lower in P+ than in G+P- patients. LA contractile function did not differ between the groups (31% vs 32%, P = .87). Compared with patients with G+P- HCM, those with P+HCM had lower four-chamber LASr (29% vs 41%, P < .001), two-chamber LASr (30% vs 41%, P < .001), average LASr (29% vs 42%, P < .001), and LA contractile strain (9% vs 12%, P = .016). In the cohort of patients with HCM who underwent stress testing (n = 35), LA conduit function weakly correlated with aerobic capacity (r = 0.42, P = .019).
Conclusions
Children with P+HCM have reduced LA function, measurable by both volumetric and strain analysis. Altered LA mechanics are associated with poor exercise capacity. This study lays the foundation for the evaluation of novel LA parameters in pediatric HCM and warrants larger longitudinal studies to assess its clinical significance.

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

J Am Soc Echocardiogr: 26 Apr 2021; epub ahead of print
Jhaveri S, Komarlu R, Worley S, Shahbah D, Gurumoorthi M, Zahka K
J Am Soc Echocardiogr: 26 Apr 2021; epub ahead of print | PMID: 33915246
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This program is still in alpha version.