Journal: J Am Soc Echocardiogr

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Abstract

Sex, Age and Race Related Normal Values of Right Ventricular Diastolic Function Parameters: Data from the World Alliance of Societies of Echocardiography Study.

Singulane CC, Singh A, Miyoshi T, Addetia K, ... Asch FM, Lang RM
Background
Though the assessment of right ventricular (RV) diastolic function is feasible, it has garnered far less momentum for use compared to its left ventricular counterpart. The scarcity of data defining normative RV diastolic function and the fact that implications of RV diastolic dysfunction in different disease states on outcomes are less well known, both hinder integration into routine clinical assessment. We sought to establish normal values of RV diastolic parameters stratified by sex, age and race using data from the World Alliance of Societies of Echocardiography (WASE) Study.
Methods
We analyzed a subset of 888 normal subjects from the WASE database, including measurements of tricuspid valve (TV) inflow E- and A-wave velocities, E-wave deceleration time, TV annular tissue Doppler e\' and a\' velocities. Additionally, right atrial (RA) maximal volume and RA peak reservoir strain were measured. Patients were grouped by age (<40, 41-65, >65 years), and stratified by sex and race. Differences were analyzed using unpaired t-tests.
Results
When compared to men, women had significantly higher TV e\', E-wave and A-wave velocities, though differences were modest. Increasing age was associated with stepwise lower TV E-wave, e\' velocities and TV E/A, higher a\' velocities and E/e\' ratios. RA peak reservoir strain was also lower and RA ESV trended towards being smaller for older age groups. Asian subjects demonstrated significantly higher a\' velocities, lower E-wave, smallest RA ESV and lowest RA peak strain values, compared to whites of both sexes.
Conclusions
This study provides normal values for parameters used in the assessment of RV diastolic function stratified by race, sex and age. Our results demonstrate significant differences in RV diastolic parameters between age groups, which manifest in both the individual parameters and composite ratios of TV inflow and annular velocities. While limited sex- and race-related differences were also noted, age appears to have the most significant impact on RV diastolic parameters. These findings may aid in refining the current normative values.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 21 Oct 2021; epub ahead of print
Singulane CC, Singh A, Miyoshi T, Addetia K, ... Asch FM, Lang RM
J Am Soc Echocardiogr: 21 Oct 2021; epub ahead of print | PMID: 34695547
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Abstract

Echocardiographic Variables Associated with Transvalvular Gradient after a Transcatheter Edge-to-Edge Mitral Valve Repair.

Hadjadj S, Freitas-Ferraz AB, Paquin A, Rouleau Z, ... Paradis JM, Beaudoin J
Background
Transcatheter edge-to-edge mitral valve repair (TMVr) may lead to a reduction in the mitral valve area (MVA) and elevated mean transmitral gradients (TMG). The objectives of this study are to assess the value of baseline MVA by different imaging methods and explore the association between MVA indexed by 1) the body surface area (BSA); and 2) the left ventricular (LV) forward stroke volume (SV) with post-procedural TMG.
Methods
Pre-procedural echocardiographic images were retrospectively reviewed in 76 consecutive patients. MVA planimetry from 2D transthoracic (MVATTE), 2D transesophageal in the transgastric view (MVA2D TEE) and 3D transesophageal (MVA3D) echocardiography were measured. Post-procedural TMG were assessed at 1-3 months and all-cause mortality at one year.
Results
Post-procedural mean TMG >5 mmHg was associated with a 3.42-fold (95% CI 1.08-10.87; p=0.04) increased risk of 1-year all-cause mortality. Patients with post-procedural TMG >5 mmHg (25%, 19/76) had significantly smaller pre-procedural MVA3D (3.9±0.8 vs 5.2±1.3 cm2, p<0.01) and MVATTE (4.9±1.1 vs 5.8±1.5 cm2, p=0.01) compared to patients without elevated TMG. No significant difference was found for MVA2D TEE (p=0.2). Best threshold values for MVA3D and MVATTE to be associated with post-procedural TMG >5 mmHg were respectively 3.9 cm2 (AUC=0.80, IC95%: 0.66-0.94; sensitivity (Se) 62%, specificity (Sp) 87%) and 4.6 cm2 (AUC=0.68, IC95%: 0.54-0.82; Se 53%, Sp 80%). MVA3D/BSA and MVA3D/SV showed overall the best association with post-procedural mean TMG >5 mmHg, with optimal thresholds respectively of 2.5 cm2/m2 (AUC=0.88, IC95%: 0.77-0.98; Se 92%, Sp 74%) and 95 cm2/L (AUC=0.87, IC95%: 0.77-0.97; Se 85%, Sp 82%).
Conclusions
Elevated TMG following TMVr was associated with increased mortality. Our results indicate that MVA3D, MVA3D/BSA and MVA3D/SV may be considered as potential predictors for post-procedural TMG>5 mmHg and could help optimize patient selection while the use of 2D methods for valve area were poorly associated with TMG.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 11 Oct 2021; epub ahead of print
Hadjadj S, Freitas-Ferraz AB, Paquin A, Rouleau Z, ... Paradis JM, Beaudoin J
J Am Soc Echocardiogr: 11 Oct 2021; epub ahead of print | PMID: 34653599
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Abstract

Normal Values of Aortic Root Size According to Age, Sex and Race: Results of the World Alliance of Societies of Echocardiography Study.

Patel HN, Miyoshi T, Addetia K, Citro R, ... Lang RM, WASE Investigators
Background
Accurate measurements of the aortic annulus and root are important for guiding therapeutic decisions regarding the need for aortic surgery. Current echocardiographic guidelines for identification of aortic root dilatation are limited because current normative values were derived predominantly from white individuals in narrow age ranges, and based partially on M-mode measurements. Using data from the World Alliance Societies of Echocardiography (WASE) Study, we sought to establish normal ranges of aortic dimensions across sexes, races and a wide range of ages.
Methods
Adult individuals free from heart, lung and kidney disease were prospectively enrolled from 15 countries with even distribution among sexes and age groups: young (18-40), middle (41-65) and old (>65 years). Transthoracic 2D echocardiograms of 1,585 subjects (age 47±17 years, 50.4% male, body surface area (BSA) 1.77±0.22 m2) were analyzed in a core laboratory following ASE guidelines. Measurements, indexed separately by BSA and by height, included the aortic annulus, sinuses of Valsalva (SoV), and sinotubular junction (STJ). Differences among age, sex and racial groups were evaluated using unpaired two-tailed student\'s t-tests.
Results
All aortic root dimensions were larger in males compared to females. After indexing to BSA, all measured dimensions were significantly larger in females, whereas males continued to show larger dimensions after indexing to height. Of note, the upper limits of normal for all aortic dimensions were lower across all age groups, compared to the guidelines. Aortic dimensions were larger in older age groups in both sexes, a trend that persisted regardless of BSA- or height adjustment. Lastly, differences in aortic dimensions were also observed according to race: Asians had the smallest non-indexed aortic dimensions at all levels.
Conclusions
There are significant differences in aortic dimensions according to sex, age, and race. Thus, current guideline-recommended normal ranges may need to be adjusted to account for these differences.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 03 Oct 2021; epub ahead of print
Patel HN, Miyoshi T, Addetia K, Citro R, ... Lang RM, WASE Investigators
J Am Soc Echocardiogr: 03 Oct 2021; epub ahead of print | PMID: 34619294
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Abstract

Association of Global Cardiac Calcification with Atrial Fibrillation and Recurrent Stroke in Patients with Embolic Stroke of Undetermined Source.

Li TYW, Yeo LLL, Ho JSY, Leow AS, ... Tan BY, Sia CH
Background
Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke, and atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for the assessment of patients with embolic stroke of undetermined source (ESUS). The aim of this study was to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS.
Methods
In this study, 181 consecutive patients with stroke diagnosed with ESUS were identified and evaluated. They were followed for new-onset AF and ischemic stroke recurrence for a median duration of 2.1 years. Various echocardiographic cardiac calcification scores were assessed on transthoracic echocardiography performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (1) global cardiac calcium score (GCCS), (2) echocardiographic calcium score (eCS), (3) echocardiographic calcification score, (4) echocardiographic composite cardiac calcium score, and (5) total heart calcification score. Only two of these scoring schemes, GCCS and eCS, quantified the cardiac calcium burden.
Results
Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF.
Conclusions
Higher cardiac calcification measured using the GCCS and eCS is independently associated with AF detection and recurrent ischemic stroke in patients with ESUS, and these scores can be useful markers for further risk stratification in patients with ESUS.

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

J Am Soc Echocardiogr: 29 Sep 2021; 34:1056-1066
Li TYW, Yeo LLL, Ho JSY, Leow AS, ... Tan BY, Sia CH
J Am Soc Echocardiogr: 29 Sep 2021; 34:1056-1066 | PMID: 33872703
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Abstract

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

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

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

J Am Soc Echocardiogr: 29 Sep 2021; 34:1025-1037
Flint N, Price MJ, Little SH, Mackensen GB, ... Makar M, Siegel RJ
J Am Soc Echocardiogr: 29 Sep 2021; 34:1025-1037 | PMID: 33872701
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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: 29 Sep 2021; 34:1067-1076.e3
Jeyaprakash P, Moussad A, Pathan S, Sivapathan S, ... Negishi K, Pathan F
J Am Soc Echocardiogr: 29 Sep 2021; 34:1067-1076.e3 | PMID: 34023453
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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: 29 Sep 2021; 34:1077-1085.e1
Patel HN, Miyoshi T, Addetia K, Henry MP, ... Lang RM, WASE Investigators
J Am Soc Echocardiogr: 29 Sep 2021; 34:1077-1085.e1 | PMID: 34044105
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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: 29 Sep 2021; 34:1038-1045
Italia L, Adamo M, Lupi L, Scodro M, Curello S, Metra M
J Am Soc Echocardiogr: 29 Sep 2021; 34:1038-1045 | PMID: 34052316
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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: 29 Sep 2021; 34:1095-1105.e6
Papachristidis A, Queirós S, Theodoropoulos KC, D'hooge J, ... Murgatroyd FD, Monaghan MJ
J Am Soc Echocardiogr: 29 Sep 2021; 34:1095-1105.e6 | PMID: 34082020
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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: 29 Sep 2021; 34:1086-1094
Paudel G, Johnson JN, Philip R, Tailor N, ... Waller BR, Sathanandam S
J Am Soc Echocardiogr: 29 Sep 2021; 34:1086-1094 | PMID: 34139301
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Abstract

Association of Left Atrial Metrics with Atrial Fibrillation Rehospitalization and Adverse Cardiovascular Outcomes in Patients with Nonvalvular 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 and LA emptying fraction (LAEF), respectively, for AF rehospitalization and long-term adverse outcomes in patients with nonvalvular 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 center with nonvalvular 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.
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; 95% CI, 0.953-0.982; P < .01), and time-dependent receiver operating characteristic curves demonstrated LAEF to have strong diagnostic accuracy in predicting early and intermediate AF rehospitalization. Both LA volume index (HR = 1.014; 95% CI, 1.003-1.026; P = .01) and LAEF (HR = 0.982; 95% CI, 0.970-0.993; P < .01) were associated with all-cause death and major adverse cardiovascular events.
Conclusions
Adverse LA remodeling, 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 nonvalvular AF.

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

J Am Soc Echocardiogr: 29 Sep 2021; 34:1046-1055.e3
Bhat A, Gan GCH, Chen HHL, Khanna S, ... MacIntyre CR, Tan TC
J Am Soc Echocardiogr: 29 Sep 2021; 34:1046-1055.e3 | PMID: 34245827
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Abstract

Prenatal Diagnosis of Vascular Ring: Evaluation of Fetal Diagnosis and Postnatal Outcomes.

Aly S, Papneja K, Mawad W, Seed M, Jaeggi E, Yoo SJ
Background
The impact of fetal echocardiography on the diagnosis and outcomes of vascular ring (VR) has not been well examined. We hypothesized that prenatal detection of VR has improved over time and that prenatal diagnosis of VR is associated with earlier intervention and favorable outcomes.
Methods
This is a single center, retrospective study of the evolution and outcomes of prenatal diagnosis of VR from 2000 to 2020. We compared clinical presentation, timing of surgical intervention and outcomes between the prenatally and postnatally diagnosed cases during the same study period.
Results
A total of 170 patients were included; 50 with prenatal and 120 with a postnatal diagnosis of VR. Prenatal diagnoses included 42 patients (84%) with right aortic arch, aberrant left subclavian artery and a left-sided ductus arteriosus (RAA-ALSCA) and 8 (16%) patients with double aortic arch (DAA). The postnatal cohort consisted mainly of 90 patients (75%) with DAA and 22 (18%) with RAA-ALSCA. None of the postnatally diagnosed cases had undergone a fetal echocardiogram. Numbers (proportion) of prenatally diagnosed cases of VR compared to the postnatal cases improved from 4/31 (13%), 10/29 (34%), 14/25 (56%), to 22/35 (69%) respectively from 2000-2005, 2005-2010, 2010-2015, and 2015-2020 (p=0.032). VR was an isolated abnormality in 84% and 85% of prenatal and postnatal cohort, respectively. As compared to the prenatal cohort, postnatally diagnosed patients with an isolated VR were more frequently symptomatic (66% vs 48%, p<0.03), underwent cross-sectional imaging more frequently (69% vs 44%, p=0.009) and underwent surgery more frequently (79% vs 48%, p=0.003). Surgery was performed at later patient age [18(2-147) months vs 4.8(0.5-42) months, p=0.01] and more often associated with residual symptoms [27/81(33%) vs 1/20(5%), p=0.01] in postnatal cohort than in prenatal cohort.
Conclusion
The diagnosis of VR by fetal echocardiography has improved over time. A significantly higher incidence of RAA-ALSCA in the prenatal compared to the postnatal cohort suggests that patients with this form of VR often do not present to medical attention with significant symptoms postnatally. Prenatal diagnosis of VR was associated with a lower incidence of symptoms, less frequent use of cross-sectional imaging, earlier age at surgical intervention and lower likelihood of residual symptoms.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 28 Sep 2021; epub ahead of print
Aly S, Papneja K, Mawad W, Seed M, Jaeggi E, Yoo SJ
J Am Soc Echocardiogr: 28 Sep 2021; epub ahead of print | PMID: 34600045
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Abstract

Burden of Ventricular Arrhythmias in CRT-D and ICD Recipients with Recovered Left Ventricular Ejection Fraction: the Additive Role of Speckle Tracking Echocardiography.

Carluccio E, Biagioli P, Mengoni A, Zuchi C, ... Oliva V, Ambrosio G
Background
Heart Failure (HF) patients undergoing cardiac resynchronization therapy with (CRT-D) or without defibrillator function, may exhibit recovery of left ventricular (LV) ejection fraction (LVEF) during follow-up. Mechanical dispersion (MD, standard deviation of time-to-peak longitudinal strain by 2D-speckle-tracking echocardiography [STE]) is a known predictor of life-threatening ventricular arrhythmias (VAs). Relationships between LVEF recovery, changes in MD, and incidence of VAs are still not extensively investigated.
Methods
In this retrospective study, CRT-D (n=183) or ICD-only (n=87) recipients underwent conventional and STE, both at baseline and after 10-12-months, and were followed clinically. Both a ≥10% increase in LVEF and a final LVEF >35% defined EchoResp+. Reduction in MD ≥10 ms defined MD-responders (MDResp+). Risk of appropriate ICD therapy for VAs was assessed by multivariable Cox-hazard model.
Results
Prevalence of EchoResp+ and MDResp+ was 39% and 46%, respectively. During follow-up (49.8+33.5 months), 74 VAs events occurred. Incidence-rate (per 100 patients/year) of VAs was lowest in EchoResp+/MDResp+ (1.66% [95%CI: 0.69-3.99]), highest in EchoResp-/MDResp- (12.8%, [9.53 - 17.2] P<0.0001), and intermediate in EchoResp-/MDResp+ (5.5% [3.3-9.4]) or EchoResp+/MDResp- (5.3% [3.0 - 9.4]). Multivariable analysis showed that higher MD at follow-up (>71.4 ms) was associated with VAs independent of whether the final LVEF was below or above the guideline-reported cut-off of 35% (P<0.05).
Conclusions
Among ICD recipients, both improvement in LV function and MD are associated with a reduced risk of VAs. In patients whose follow-up LVEF improved to >35%, risk of VAs, although substantially decreased, remained elevated in the presence of still elevated MD.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 22 Sep 2021; epub ahead of print
Carluccio E, Biagioli P, Mengoni A, Zuchi C, ... Oliva V, Ambrosio G
J Am Soc Echocardiogr: 22 Sep 2021; epub ahead of print | PMID: 34563638
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Abstract

The Diagnostic Yield of Fetal Echocardiography Indications in the Current Era.

Boehme C, Fruitman D, Eckersley L, Low R, ... Pastuck M, Hornberger LK
Background
We sought to examine the diagnostic yield of current fetal echocardiography (FE) indications representing a recent era.
Methods
We examined the FE reports of all pregnancies referred to two provincial FE programs in 2009-2018, identifying the indication for FE (14 categories), gestational age at referral, and whether there was 1) no fetal heart disease (FHD), 2) mild/possible FHD (e.g., simple ventricular septal defect, possible coarctation), or 3) moderate/severe FHD.
Results
Over the study period, there were 19,310 unique FE referrals in Alberta (23.3±5.4 weeks gestation), including 1907 (9.9%) with moderate/severe and 654 (3.4%) with mild/possible FHD. The most common referral indications included: extracardiac pathology/markers (29.7%), maternal diabetes (18.3%), suspected FHD and family history of heart defects (17.7% each). Highest yield for moderate/severe FHD was suspected FHD (41.1%; 95% confidence interval: 39.4, 42.7%), followed by suspected/confirmed genetic disorder (15.4%; 12.6, 18.2%), twins/multiples (10.6%; 8.7, 12.5%), oligohydramnios (8.0%; 4.1, 11.9%), extracardiac pathology/markers (6.4%; 5.8, 7.1%) and heart not well seen (5.8%; 4.0, 7.6%). Lowest yields were observed in maternal diabetes (2.2%; 1.7, 2.7%) and family history of heart defects (1.7%; 1.3, 2.2%). Excluding suspected FHD, with >2 FE indications all other indications demonstrated a significant increase in yield of mild/possible (3.5% vs 1.9%, p<0.001) and moderate/severe (7.2% vs 2.9%, p<0.001) FHD.
Conclusions
Suspected FHD provides the highest diagnostic yield of moderate/severe FHD. In contrast, maternal diabetes and family history of heart defects, among the most common referral indications, had diagnostic yields approaching general population risks. Even in the absence of suspected FHD, having >2 referral indications importantly increases the diagnostic yield of all other FE indications.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 12 Sep 2021; epub ahead of print
Boehme C, Fruitman D, Eckersley L, Low R, ... Pastuck M, Hornberger LK
J Am Soc Echocardiogr: 12 Sep 2021; epub ahead of print | PMID: 34530071
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Impact:
Abstract

Mitral Annular Disjunction of Degenerative Mitral Regurgitation: Three-Dimensional Evaluation and Implications for Mitral Repair.

Essayagh B, Mantovani F, Benfari G, Maalouf JF, ... Michelena HI, Enriquez-Sarano M
Background
The dynamic consequences of mitral annular disjunction (MAD) on the mitral apparatus and the left ventricle remain unclear and are crucial in the context of mitral surgery. Thus, the aim of this study was to assess mitral valvular, annular, and ventricular dynamics in mitral valve prolapse (MVP) stratified by presence of MAD.
Methods
In 61 patients (mean age, 62 ± 11 years; 25% women) with MVP and severe mitral regurgitation undergoing mitral surgery between 2009 and 2016, valvular and annular dimensions and dynamics by two-dimensional transthoracic and three-dimensional transesophageal echocardiography and left ventricular dimensions and dynamics were analyzed stratified by presence of MAD before and after surgery.
Results
MAD (mean, 8 ± 3 mm) was diagnosed in 27 patients (44%; with a mean effective regurgitant orifice area of 0.55 ± 0.20 cm2 and similar to patients without MAD), more frequently in bileaflet prolapse (52% vs 18% in patients without MAD, P = .004), consistently involving P2 (P = .005). Patients with MAD displayed larger diastolic annular areas (mean, 1,646 ± 410 vs 1,380 ± 348 mm2), circumferences (mean, 150 ± 19 vs 137 ± 16 mm), and intercommissural diameters (mean, 48 ± 7 vs 43 ± 6 mm) compared with those without MAD (P ≤ .008 for all). Dynamically, mid- and late systolic excess intercommissural diameter, annular area, and circumference enlargement were associated with MAD (P ≤ .01 for all). MAD was also associated with dynamically annular slippage, larger prolapse volume and height (P ≤ .007), and larger leaflet area (mean, 2,053 ± 620 vs 1,692 ± 488 mm2, P = .01). Although patients with MAD compared with those without MAD showed similar ejection fractions (mean, 65 ± 5% vs 62 ± 8%, respectively, P = .10), systolic basal posterior thickness was increased in patients with MAD (mean, 19 ± 2 vs 15 ± 2 mm, P < .001), with higher systolic thickening of the basal posterior wall (mean, 74 ± 27% vs 50 ± 28%) and higher ratio of basal wall thickness to diameter (P ≤ .01 for both). However, after mitral repair, MAD disappeared, and LV diameter, wall thickness, and wall thickening showed no difference between patients with MAD and those without MAD (P ≥ .10 for all).
Conclusions
MAD in patients with MVP involves a predominant phenotype of bileaflet MVP and causes profound annular dynamic alterations with considerable expansion and excess annular enlargement in systole, potentially affecting leaflet coaptation. MAD myocardial and annular slippage simulates vigorous left ventricular function without true benefit after surgical annular suture. Thus, although MAD does not hinder the feasibility and quality of valve repair, it requires careful suture of ring to ventricular myocardium, lest it persist postoperatively.

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

J Am Soc Echocardiogr: 09 Sep 2021; epub ahead of print
Essayagh B, Mantovani F, Benfari G, Maalouf JF, ... Michelena HI, Enriquez-Sarano M
J Am Soc Echocardiogr: 09 Sep 2021; epub ahead of print | PMID: 34517112
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Impact:
Abstract

Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement.

Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, ... Oh JK, Nkomo VT
Background
Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).
Methods
Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography.
Results
Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39-0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41-0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS.
Conclusions
AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

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

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, ... Oh JK, Nkomo VT
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34506919
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Impact:
Abstract

Feasibility and Accuracy of Automated Three-Dimensional Echocardiographic Analysis of Left Atrial Appendage for Transcatheter Closure.

Morais P, Fan Y, Queirós S, D\'hooge J, Lee AP, Vilaça JL
Background
Procedural success of transcatheter left atrial appendage closure (LAAC) is dependent on correct device selection. Three-dimensional (3D) transesophageal echocardiography (TEE) is more accurate than the two-dimensional modality for evaluation of the complex anatomy of the left atrial appendage (LAA). However, 3D transesophageal echocardiographic analysis of the LAA is challenging and highly expertise dependent. The aim of this study was to evaluate the feasibility and accuracy of a novel software tool for automated 3D analysis of the LAA using 3D transesophageal echocardiographic data.
Methods
Intraprocedural 3D transesophageal echocardiographic data from 158 patients who underwent LAAC were retrospectively analyzed using a novel automated LAA analysis software tool. On the basis of the 3D transesophageal echocardiographic data, the software semiautomatically segmented the 3D LAA structure, determined the device landing zone, and generated measurements of the landing zone dimensions and LAA length, allowing manual editing if necessary. The accuracy of LAA preimplantation anatomic measurement reproducibility and time for analysis of the automated software were compared against expert manual 3D analysis. The software feasibility to predict the optimal device size was directly compared with implanted models.
Results
Automated 3D analysis of the LAA on 3D TEE was feasible in all patients. There was excellent agreement between automated and manual measurements of landing zone maximal diameter (bias, -0.32; limits of agreement, -3.56 to 2.92), area-derived mean diameter (bias, -0.24; limits of agreement, -3.12 to 2.64), and LAA depth (bias, 0.02; limits of agreement, -3.14 to 3.18). Automated 3D analysis, with manual editing if necessary, accurately identified the implanted device size in 90.5% of patients, outperforming two-dimensional TEE (68.9%; P < .01). The automated software showed results competitive against the manual analysis of 3D TEE, with higher intra- and interobserver reproducibility, and allowed quicker analysis (101.9 ± 9.3 vs 183.5 ± 42.7 sec, P < .001) compared with manual analysis.
Conclusions
Automated LAA analysis on the basis of 3D TEE is feasible and allows accurate, reproducible, and rapid device sizing decision for LAAC.

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

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Morais P, Fan Y, Queirós S, D'hooge J, Lee AP, Vilaça JL
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34508840
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Impact:
Abstract

Incremental Value of Global Longitudinal Strain in the Long-Term Prediction of Heart Failure among Patients with Coronary Artery Disease.

Haji K, Marwick TH, Stewart S, Carrington M, ... Neil C, Wong C
Background
Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD.
Methods
We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in individuals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model.
Results
Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e\' (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain-but not conventional echocardiographic measures-added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26]; P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease).
Conclusions
Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention.

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

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Haji K, Marwick TH, Stewart S, Carrington M, ... Neil C, Wong C
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34508839
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Impact:
Abstract

Morphology of Mitral Annular Disjunction in Mitral Valve Prolapse.

Faletra FF, Leo LA, Paiocchi VL, Schlossbauer SA, ... Ho SY, Maisano F
Mitral annular disjunction (MAD) is an abnormal insertion of the hinge line of the posterior mitral leaflet on the atrial wall: the mitral annulus shows a separation or \"disjunction\" between the leaflet-atrial wall junction and the crest of the left ventricle myocardium. This anomaly is often observed in patients with myxomatous mitral valve prolapse. The anatomical substrate of MAD remains unclear for the following reasons: (1) most studies are focused on the association between MAD and arrhythmias, rather than on pathomorphological aspects of MAD; and (2) the complex anatomic architecture of the posterior mitral annulus is often simply described as the posterior segment of a fibrous ring. The aims of this paper are to review the pertinent normal anatomy of the mitral valve and to propose new hypotheses on the morphological nature of MAD.

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

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Faletra FF, Leo LA, Paiocchi VL, Schlossbauer SA, ... Ho SY, Maisano F
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34508838
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Impact:
Abstract

Cardiorespiratory Abnormalities in Patients Recovering from Coronavirus Disease 2019.

Szekely Y, Lichter Y, Sadon S, Lupu L, ... Banai S, Topilsky Y
Background
A large number of patients around the world are recovering from coronavirus disease 2019 (COVID-19); many of them report persistence of symptoms. The aim of this study was to test pulmonary, cardiovascular, and peripheral responses to exercise in patients recovering from COVID-19.
Methods
Patients who recovered from COVID-19 were prospectively evaluated using a combined anatomic and functional assessment. All patients underwent clinical examination, laboratory tests, and combined stress echocardiography and cardiopulmonary exercise testing. Left ventricular volumes, ejection fraction, stroke volume, heart rate, E/e\' ratio, right ventricular function, oxygen consumption (Vo2), lung volumes, ventilatory efficiency, oxygen saturation, and muscle oxygen extraction were measured in all effort stages and compared with values in historical control subjects.
Results
A total of 71 patients were assessed 90.6 ± 26 days after the onset of COVID-19 symptoms. Only 23 (33%) were asymptomatic. The most common symptoms were fatigue (34%), muscle weakness or pain (27%), and dyspnea (22%). Vo2 was lower among post-COVID-19 patients compared with control subjects (P = .03, group-by-time interaction P = .007). Reduction in peak Vo2 was due to a combination of chronotropic incompetence (75% of post-COVID-19 patients vs 8% of control subjects, P < .0001) and an insufficient increase in stroke volume during exercise (P = .0007, group-by-time interaction P = .03). Stroke volume limitation was mostly explained by diminished increase in left ventricular end-diastolic volume (P = .10, group-by-time interaction P = .03) and insufficient increase in ejection fraction (P = .01, group-by-time interaction P = .01). Post-COVID-19 patients had higher peripheral oxygen extraction (P = .004) and did not have significantly different respiratory and gas exchange parameters compared with control subjects.
Conclusions
Patients recovering from COVID-19 have symptoms associated with objective reduction in peak Vo2. The mechanism of this reduction is complex and mainly involves a combination of attenuated heart rate and stroke volume reserve.

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

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Szekely Y, Lichter Y, Sadon S, Lupu L, ... Banai S, Topilsky Y
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34508837
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Impact:
Abstract

Multiparametric Approach for the Assessment of Mechanical Prosthetic Tricuspid Leaflet Function.

Fadel BM, Alassas K, Clavel MA, Ayas MF, ... Pibarot P, Mohty D
Background
There is a lack of comprehensive echocardiographic data to allow discrimination of normal versus abnormal mechanical prosthetic tricuspid valve (MPTV) leaflet function. The identification of such parameters is essential to optimize diagnostic and therapeutic measures.
Methods
The authors investigated bileaflet MPTV function by comparing transthoracic echocardiographic data from 21 episodes of leaflet dysfunction due to valve thrombosis in 12 patients with data from 56 individuals with normal MPTV function. All episodes of dysfunction were confirmed by transesophageal echocardiography and/or cine fluoroscopy. Transthoracic echocardiography-derived two-dimensional, color, and spectral Doppler variables, including MPTV peak early diastolic velocity (E velocity), mean gradient, pressure half-time, time-velocity integral (TVI) of the MPTV, ratio of TVIMPTV to TVI of the left ventricular outflow tract (LVOT) and TVI of the right ventricular outflow tract (RVOT), and continuity-derived effective orifice area, were measured in both groups.
Results
Most episodes of MPTV dysfunction resulted from simultaneous involvement of both leaflets (57%), with leaflet(s) often immobilized in the open or semiopen position (71%). Transthoracic and transesophageal echocardiography performed similarly in detecting abnormal leaflet motion (90% vs 88%, P = .68), whereas transesophageal echocardiography was better in identifying MPTV thrombosis (31% vs 14%, respectively, P = .01). Color Doppler demonstrated flow propagation abnormalities in 67% of episodes of leaflet dysfunction but not in the control group (P < .0001). Doppler variables associated with MPTV leaflet dysfunction included E velocity > 1.6 m/sec, mean gradient > 5 mm Hg, PHT > 157 msec, TVIMPTV > 42 cm, TVIMPTV/TVILVOT > 2.3, TVIMPTV/TVIRVOT > 3.0, and continuity-derived effective orifice area ≤ 1.1 cm2, with most variables showing high and similar accuracy (area under the curve ≥ 95%).
Conclusions
This study represents the first comprehensive echocardiographic assessment of MPTV leaflet dysfunction that provides parameters and criteria to distinguish normal versus abnormal prosthetic valve function.

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

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Fadel BM, Alassas K, Clavel MA, Ayas MF, ... Pibarot P, Mohty D
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34508836
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Impact:
Abstract

Anatomical and Technical Predictors of Three-dimensional Mitral Valve Area Reduction after Transcatheter Edge-to-Edge Repair.

Kassar M, Praz F, Hunziker L, Pilgrim T, ... Seiler C, Nicolas B
Background
Among current transcatheter therapies for the treatment of mitral regurgitation, the MitraClipTM (MC, Abbott Vascular, Illinois, USA) system is the most commonly used. MC implantation is usually contraindicated in patients with a mitral valve area (MVA) < 4.0cm2. However, little is known about the real impact of MC implantation on MVA. Our goal was to investigate the factors influencing MVA reduction and derive the minimal MVA required to prevent the development of a clinically significant mitral stenosis (MVA < 1.5cm2) in different clinical scenarios.
Methods
Using 3D datasets, the annulus and leaflet anatomy, and MVA before clip implantation (MVABC) were assessed. After each MC implant (NTR or XTR), the relative MVA reduction and the absolute residual MVA were measured and their predictors evaluated.
Results
The present analysis included 116 patients. A MC XTR was the first device implanted in 50% of the subjects, and 53% were treated with a single implant. MVA reduction following one XTR was 57±7% vs. 52±8% after one NTR (p=0.001). A lower MVA reduction was observed when the MC was placed commissural/central versus paracentral (50±8 vs. 57±7%, p<0.0001). After a second device, the additional MVA reduction was higher when creating a triple- than a double-orifice morphology (34±11 vs. 25±9%, p=0.001). MVA after one MC correlated with MVABC, as well as with the clip type and position (r=0.91, p<0.0001). MVABC, orifice morphology, and first device position predicted MVA after two implants (r=0.82, p<0.0001). Based on the mathematical relationship between these parameters, the minimal MVABC needed in eight different clinical scenarios was summarized in a decision algorithm: the values ranged from 3.5 to 4.7cm2 for one and 4.5 to 6.3cm2 for two MC strategies.
Conclusion
The minimal native MVA preventing clinically relevant MS after transcatheter edge-to-edge repair is predicted by the number and location of clip(s), orifice morphology, and device type. Based on these parameters an algorithm has been derived to optimize patient selection and pre-procedural planning.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Sep 2021; epub ahead of print
Kassar M, Praz F, Hunziker L, Pilgrim T, ... Seiler C, Nicolas B
J Am Soc Echocardiogr: 06 Sep 2021; epub ahead of print | PMID: 34506920
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Impact:
Abstract

Three-Dimensional Echocardiographic Left Atrial Appendage Volumetric Analysis.

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

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

J Am Soc Echocardiogr: 30 Aug 2021; 34:987-995
Meltzer SN, Phatak PM, Fazlalizadeh H, Chang I, ... Kumar P, Medvedofsky D
J Am Soc Echocardiogr: 30 Aug 2021; 34:987-995 | PMID: 33775733
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Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 30 Aug 2021; 34:923-931
Silbiger JJ
J Am Soc Echocardiogr: 30 Aug 2021; 34:923-931 | PMID: 33857624
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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: 30 Aug 2021; 34:955-965
Medvedofsky D, Milhorini Pio S, Weissman NJ, Namazi F, ... Asch FM, COAPT Investigators
J Am Soc Echocardiogr: 30 Aug 2021; 34:955-965 | PMID: 33845158
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Impact:
Abstract

Ratio between Vena Contracta Width and Tricuspid Annular Diameter: Prognostic Value in Secondary Tricuspid Regurgitation.

Fortuni F, Dietz MF, Prihadi EA, van der Bijl P, ... Delgado V, Marsan NA
Background
Conventional approaches for the assessment of secondary tricuspid regurgitation (STR) severity do not correct for right heart dimensions. The authors hypothesized that STR severity can be proportional or disproportional to the dilation of the tricuspid annulus (TA) and investigated the prognostic impact of this novel definition.
Methods
A total of 334 patients with moderate to severe STR and preserved left ventricular systolic function were included. The ratio between vena contracta (VC) width and tricuspid annular diameter was calculated. The cutoff value for VC/TA ratio associated with increased risk for all-cause death was identified using spline-curve analysis.
Results
The cutoff value of VC/TA ratio associated with a mortality excess was 0.24, and 165 patients (49%) had VC/TA ratios ≥ 0.24. Compared with those with VC/TA ratios < 0.24, patients with VC/TA ratios ≥ 0.24 had a higher prevalence of moderate to severe mitral regurgitation, had higher pulmonary pressures, and were more frequently treated with diuretics. During a median follow-up period of 62 months (interquartile range, 28-101 months), 128 patients (38%) died. The cumulative 5-year survival rate was significantly worse in patients with VC/TA ratios ≥ 0.24 (55% vs 71%, P = .001). VC/TA ratio ≥ 0.24 was independently associated with poor outcomes on multivariate analysis (hazard ratio, 1.567; 95% CI, 1.044-2.352; P = .030) together with coronary artery disease, renal impairment, right ventricular systolic function (evaluated using either tricuspid annular plane systolic excursion or right ventricular free wall strain), and pulmonary pressures.
Conclusions
VC/TA ratio ≥ 0.24 is independently associated with poor prognosis in patients with STR. This parameter may be considered as a marker of disproportionate STR and could improve risk stratification and clinical decision-making.

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

J Am Soc Echocardiogr: 30 Aug 2021; 34:944-954
Fortuni F, Dietz MF, Prihadi EA, van der Bijl P, ... Delgado V, Marsan NA
J Am Soc Echocardiogr: 30 Aug 2021; 34:944-954 | PMID: 33839257
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Impact:
Abstract

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

Torii Y, Kusunose K, Hirata Y, Nishio S, ... Wakatsuki T, Sata M
Background
Heart failure with recovered ejection fraction (HFrecEF) has been reported in several previous studies to have a better prognosis than heart failure with reduced ejection fraction (HFrEF). However, the factors associated with HFrecEF have not been identified. The aim of this study was to test the hypothesis that left atrial (LA) strain could help identify patients with recovered ejection fraction (EF) among those with heart failure (HF) with low EF on admission.
Methods
One hundred consecutive patients hospitalized for the first time for new-onset HF were enrolled. Patients were clinically diagnosed with HFrEF on admission (left ventricular EF < 40%) and received optimal treatment for HF. Twenty-eight patients improved to HFrecEF during 6 months of follow-up.
Results
Regarding clinical background, there were significantly more women and a lower rate of atrial fibrillation in the HFrecEF group than in the HFrEF group. In a multivariate logistic regression analysis, LA strain was an independent predictor of HFrecEF, even after adjustment for gender and left ventricular EF (odds ratio: 4.06; 95% CI: 2.04-8.07; P < .001). A cutoff value of 10.8% for LA strain showed high sensitivity (96%) and specificity (82%) in identifying HFrecEF in patients with HF presenting with low EF on admission. During a follow-up period of 24 ± 13 months, 31 patients (31%) had cardiovascular death or readmission for HF. Patients with reduced LA strain (<10.8%) had significantly shorter event-free survival than those with preserved LA strain (P = .02).
Conclusions
LA strain is a useful indicator for predicting HFrecEF and should be considered as a routine measurement in patients with HFrEF on admission.

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

J Am Soc Echocardiogr: 30 Aug 2021; 34:966-975.e2
Torii Y, Kusunose K, Hirata Y, Nishio S, ... Wakatsuki T, Sata M
J Am Soc Echocardiogr: 30 Aug 2021; 34:966-975.e2 | PMID: 33852960
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Abstract

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

Arangalage D, Cattan L, Eugène M, Cimadevilla C, ... Vahanian A, Messika-Zeitoun D
Background
The contribution of exercise echocardiography in primary asymptomatic mitral regurgitation (MR) remains debated. The aim of this study was to gain evidence regarding its usefulness in this setting and to investigate the prognostic value of peak exercise systolic pulmonary artery pressure (SPAP).
Methods
One hundred seventy-seven patients (mean age, 56 ± 13 years; 69% men) with moderate to severe (grade 3+) or severe (grade 4+) degenerative MR and preserved left ventricular ejection fraction, in sinus rhythm, referred for clinically indicated exercise echocardiography were identified. The end point, MR-related events, was a composite of all-cause death or occurrence of symptoms, heart failure, atrial fibrillation, left ventricular ejection fraction < 60%, left ventricular end-systolic diameter ≥ 45 mm, or resting SPAP > 50 mm Hg.
Results
At rest, effective regurgitant orifice area was 48 ± 16 mm2, regurgitant volume 74 ± 26 mL, and SPAP 32 ± 7 mm Hg, and MR was severe in 138 patients (78%). Peak exercise SPAP was 55 ± 10 mm Hg. Positive results on exercise testing motivated surgery in 26 patients, 11 underwent prophylactic surgery, 10 were lost to follow-up, and 130 were included in the outcome analysis. During a follow-up period of 19 ± 7 months, 31 MR-related events (24%) were reported. Peak exercise SPAP was predictive of outcomes in univariate analysis (P = .01) and after adjustment for age, gender, MR severity, and resting SPAP (P < .05). Peak exercise SPAP ≥ 50 mm Hg was associated with worse event-free survival (hazard ratio, 5.24; 95% CI, 1.77-15.53; P = .003), but not the threshold of ≥60 mm Hg proposed in previous guidelines (hazard ratio, 1.70; 95% CI, 0.71-4.03; P = .24).
Conclusions
The present findings support the use of exercise echocardiography for risk stratification in patients with asymptomatic primary MR and suggest a lower peak exercise SPAP threshold (50 mm Hg) than previously recommended to define the timing of intervention. Prospective studies are needed to confirm these findings.

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

J Am Soc Echocardiogr: 30 Aug 2021; 34:932-940
Arangalage D, Cattan L, Eugène M, Cimadevilla C, ... Vahanian A, Messika-Zeitoun D
J Am Soc Echocardiogr: 30 Aug 2021; 34:932-940 | PMID: 33872700
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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: 30 Aug 2021; 34:996-1006
Jhaveri S, Komarlu R, Worley S, Shahbah D, Gurumoorthi M, Zahka K
J Am Soc Echocardiogr: 30 Aug 2021; 34:996-1006 | PMID: 33915246
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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: 30 Aug 2021; 34:1007-1016.e10
Zidere V, Vigneswaran TV, Syngelaki A, Charakida M, ... Simpson JM, Akolekar R
J Am Soc Echocardiogr: 30 Aug 2021; 34:1007-1016.e10 | PMID: 33957251
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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: 30 Aug 2021; 34:976-986
Riolet C, Menet A, Mailliet A, Binda C, ... Tribouilloy C, Marechaux S
J Am Soc Echocardiogr: 30 Aug 2021; 34:976-986 | PMID: 34157400
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Abstract

Screening of Native Valvular Heart Disease using a Pocket-Sized Transthoracic Echocardiography Device.

Kikoïne J, Hauguel-Moreau M, Hergault H, Aidan V, ... Szymanski C, Mansencal N
Aims
We assessed the performance of pocket-sized transthoracic echocardiography (pTTE) compared to standard transthoracic echocardiography (sTTE) and auscultation for an early screening of valvular heart disease (VHD). Early diagnosis of significant VHD is a real challenge, and enables appropriate follow-up and implementation of the best therapeutic strategy.
Methods
STTE, pTTE and auscultation were performed by three different experienced physicians in 284 unselected patients. All cases of VHD detected by each of these three techniques were noted. sTTE was the gold standard. Each physician performed one examination and was blinded to the results of other exams.
Results
We diagnosed a total of 301 VHD cases with a large predominance of regurgitant lesions: 269 (89.3%) of regurgitant VHD and 32 (10.7%) of stenotic VHD. pTTE was highly sensitive (85.7%) and specific (97.9%) for screening VHD, while auscultation detected only 54.1%. All significant VHD cases (at least mild severity) were detected by pTTE. The weighted Kappa between pTTE and sTTE for the assessment of mitral regurgitation was 0.71 (95% CI, 0.70-0.72), indicating good agreement. The weighted Kappa between pTTE and sTTE for the assessment of aortic regurgitation and aortic stenosis was 0.97 (95% CI, 0.96-0.98) and 0.98 (95% CI, 0.97-0.99), respectively, indicating excellent agreement.
Conclusion
PTTE performed by physicians with a level III competency in echocardiography is reliable for identifying significant VHD and should be proposed as a new screening tool.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Aug 2021; epub ahead of print
Kikoïne J, Hauguel-Moreau M, Hergault H, Aidan V, ... Szymanski C, Mansencal N
J Am Soc Echocardiogr: 26 Aug 2021; epub ahead of print | PMID: 34461249
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Impact:
Abstract

Lung Ultrasound Imaging: A Primer for Echocardiographers.

Yuriditsky E, Horowitz JM, Panebianco NL, Sauthoff H, Saric M
Lung ultrasound (LUS) has gained considerable acceptance in emergency and critical care medicine but is yet to be fully implemented in cardiology. Standard imaging protocols for LUS in acute care settings have allowed the rapid and accurate diagnosis of dyspnea, respiratory failure, and shock. LUS is greatly additive to echocardiography and is superior to auscultation and chest radiography, particularly when the diagnosis of acute decompensated heart failure is in question. In this review, the authors describe LUS techniques, interpretation, and clinical applications, with the goal of informing cardiologists on the imaging modality. Additionally, the authors review LUS findings associated with various disease states most relevant to cardiac care. Although there is extensive literature on LUS in the acute care setting, there is a dearth of reviews directly focused for practicing cardiologists. Current evidence demonstrates that this modality is an important adjunct to echocardiography, providing valuable clinical information at the bedside.

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

J Am Soc Echocardiogr: 19 Aug 2021; epub ahead of print
Yuriditsky E, Horowitz JM, Panebianco NL, Sauthoff H, Saric M
J Am Soc Echocardiogr: 19 Aug 2021; epub ahead of print | PMID: 34425194
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Impact:
Abstract

Normal Values of Left Atrial Size and Function and the Impact of Age: Results of the World Alliance Societies of Echocardiography Study.

Singh A, Carvalho Singulane C, Miyoshi T, Prado AD, ... Lang RM, WASE Investigators
Background
Left atrial (LA) evaluation includes volumetric and functional parameters with an abundance of diagnostic and prognostic implications. Solid normal reference ranges are compulsory for accurate interpretation in individual patients, but previous studies have yielded mixed conclusions regarding the effects of age, sex, and/or race. The present report from the World Alliance Societies of Echocardiography study focuses on two-dimensional (2D) and three-dimensional (3D) measures of LA structure and function, with subgroup analysis by age, sex, and race.
Methods
Transthoracic 2D and 3D echocardiographic images were obtained in 1,765 healthy individuals (901 men, 864 women) evenly distributed among age subgroups: 18 to 40 years (n = 745), 41 to 65 years (n = 618), and >65 years (n = 402); the racial distribution was 38.4% white, 39.9% Asian, and 9.7% black. Images were analyzed using dedicated LA analysis software to measure LA volumes and phasic function from 3D volume and 2D strain curves.
Results
Three-dimensional maximum and minimum LA volumes adjusted for body surface area were nearly identical for men and women, but women demonstrated higher 3D total and passive emptying fractions (EFs). Two-dimensional reservoir strain was similar for both sexes. Age was associated with an incremental rise in LA volumes alongside characteristic shifts in functional indices. Total 2D EF and reservoir and conduit strain varied inversely with age, counteracted by higher booster strain, with a greater magnitude of effect in women. Active 3D EF was significantly higher, while total and passive EFs decreased with age. Interracial differences were noted in LA volumes, without substantial differences in functional indices.
Conclusion
Although similar normal values for LA volumes and strain can be applied to both sexes, meaningful differences in LA size occur with aging. Indices of function also shift with age, with a compensatory rise in booster function, which may serve to counteract observed lower total and passive EFs. Defining age-associated normal values may help differentiate age-associated \"healthy\" LA aging from pathologic processes.

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

J Am Soc Echocardiogr: 17 Aug 2021; epub ahead of print
Singh A, Carvalho Singulane C, Miyoshi T, Prado AD, ... Lang RM, WASE Investigators
J Am Soc Echocardiogr: 17 Aug 2021; epub ahead of print | PMID: 34416309
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Impact:
Abstract

Transcatheter Edge-to-Edge Repair in Proportionate Versus Disproportionate Functional Mitral Regurgitation.

Ooms JF, Bouwmeester S, Debonnaire P, Nasser R, ... Tonino PA, Van Mieghem NM
Background
Functional mitral regurgitation (FMR) can be subclassified on the basis of its proportionality relative to left ventricular (LV) volume and function, indicating potential differences in underlying etiology. The aim of this study was to evaluate the association of FMR proportionality with FMR reduction, heart failure hospitalization and mortality after transcatheter edge-to-edge mitral valve repair (TEER).
Methods
This multicenter registry included 241 patients with symptomatic heart failure with reduced LV ejection fraction treated with TEER for moderate to severe or greater FMR. FMR proportionality was graded on preprocedural transthoracic echocardiography using the ratio of the effective regurgitant orifice area to LV end-diastolic volume. Baseline characteristics, follow-up transthoracic echocardiography, and 2-year clinical outcomes were compared between groups.
Results
Median LV ejection fraction, effective regurgitant orifice area and LV end-diastolic volume index were 30% (interquartile range [IQR], 25%-35%), 27 mm2, and 107 mL/m2 (IQR, 90-135 mL/m2), respectively. Median effective regurgitant orifice area/LV end-diastolic volume ratio was 0.13 (IQR, 0.10-0.18). Proportionate FMR (pFMR) and disproportionate FMR (dFMR) was present in 123 and 118 patients, respectively. Compared with patients with pFMR, those with dFMR had higher baseline LV ejection fractions (median, 32% [IQR, 27%-39%] vs 26% [IQR, 22%-33%]; P < .01). Early FMR reduction with TEER was more pronounced in patients with dFMR (odds ratio, 0.45; 95% CI, 0.28-0.74; P < .01) than those with pFMR, but not at 12 months (odds ratio, 0.93; 95% CI, 0.53-1.63; P = .80). Overall, in 35% of patients with initial FMR reduction after TEER, FMR deteriorated again at 1-year follow-up. Rates of 2-year all-cause mortality and heart failure hospitalization were 30% (n = 66) and 37% (n = 76), with no differences between dFMR and pFMR.
Conclusions
TEER resulted in more pronounced early FMR reduction in patients with dFMR compared with those with pFMR. Yet after initial improvement, FMR deteriorated in a substantial number of patients, calling into question durable mitral regurgitation reductions with TEER in selected patients. The proportionality framework may not identify durable TEER responders.

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

J Am Soc Echocardiogr: 10 Aug 2021; epub ahead of print
Ooms JF, Bouwmeester S, Debonnaire P, Nasser R, ... Tonino PA, Van Mieghem NM
J Am Soc Echocardiogr: 10 Aug 2021; epub ahead of print | PMID: 34389469
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Impact:
Abstract

Patent Foramen Ovale Channel Morphometric Characteristics Associated with Cryptogenic Stroke: The MorPFO Score.

Hołda MK, Krawczyk-Ożóg A, Koziej M, Kołodziejczyk J, ... Jędras J, Dudek D
Background
It is still disputable whether the specific morphologic properties of patent foramen ovale (PFO) may contribute to the occurrence of stroke. The aim of this study was to evaluate the differences in the morphometric and functional features of the PFO channel in patients with cryptogenic stroke and those without stroke.
Methods
PFO channel morphology in 106 consecutive patients with cryptogenic stroke and 93 control patients without stroke with diagnosed PFO (by transesophageal echocardiography) was analyzed using transesophageal echocardiography. A validation cohort was established that consisted of 31 patients with cryptogenic stroke and 30 without stroke.
Results
Multivariable regression logistic analyses indicated PFO channel length change (odds ratio [OR], 2.50; 95% confidence interval [CI], 1.75-3.55; P < .001), PFO length/height ratio during the Valsalva maneuver (OR, 0.75; 95% CI, 0.60-0.95; P = .015), septum primum thickness (OR, 0.34; 95% CI, 0.14-0.80; P = .013), septum secundum height (OR, 0.91; 95% CI, 0.84-0.98; P = .013), the presence of an atrial septal aneurysm (OR, 3.38; 95% CI, 1.27-8.97; P = .014), and large shunt (OR, 2.49; 95% CI, 1.13-5.46; P = .022) as PFO-related stroke factors. The Morphologic Stroke Factors of PFO (MorPFO) score was developed, in which six factors were included: PFO channel length reduction (≥21%; 7 points), short septum secundum (<8.6 mm; 5 points), thin septum primum (<1.6 mm; 3 points), large right-to-left shunt (3 points), low PFO channel length/height ratio during the Valsalva maneuver (≤2.1; 2 points), and atrial septal aneurysm presence (1 point). Patients with scores of 0 to 7 points have low-risk PFO channels, those with scores of 8 to 11 points have intermediate-risk PFO channels, and those with scores of 12 to 21 points have high-risk PFO channels. External validation showed good MorPFO score performance (C index = 0.90).
Conclusions
Transesophageal echocardiography can be used to differentiate pathogenic from incidental PFO channels on the basis of their morphologic characteristics. The MorPFO score may help identify high-stroke-risk PFO channels.

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

J Am Soc Echocardiogr: 10 Aug 2021; epub ahead of print
Hołda MK, Krawczyk-Ożóg A, Koziej M, Kołodziejczyk J, ... Jędras J, Dudek D
J Am Soc Echocardiogr: 10 Aug 2021; epub ahead of print | PMID: 34389468
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Abstract

Left Ventricular Apical Aneurysms in Hypertrophic Cardiomyopathy: Equivalent Detection by Magnetic Resonance Imaging and Contrast Echocardiography.

Lee DZJ, Chan RH, Montazeri M, Hoss S, ... Nguyen ET, Rakowski H
Background
Left ventricular (LV) apical aneurysm is a unique morphological entity and novel adverse risk marker existing within the broad phenotypic spectrum of hypertrophic cardiomyopathy (HCM). Its true prevalence in the HCM population is likely underestimated because of inherent limitations of conventional noncontrast echocardiography. The authors hypothesized that contrast echocardiography is a reliable imaging technique compared with cardiovascular magnetic resonance (CMR) for the detection of apical aneurysms. The aim of this study was to assess the effectiveness of contrast echocardiography in the detection of LV apical aneurysms in patients with HCM in comparison with the gold standard, CMR.
Methods
One hundred twelve patients with HCM identified from an institutional clinical database, who underwent echocardiographic and CMR examinations within 12 months and had LV apical aneurysms identified on either or both imaging modalities, were retrospectively analyzed. Discordant cases were reviewed by an expert panel, and a consensus was reached regarding the presence or absence of an apical aneurysm. The reason for any discrepancy was recorded.
Results
The mean age of the patients was 59 ± 13 years, and 73% were men. Sixty-four (57%) underwent contrast echocardiography. The median interval between echocardiography and CMR was 118 days (interquartile range, 61-237 days). Thirty-nine patients (35%) had discordance between echocardiographic and CMR findings, of whom 20 had aneurysms reported on echocardiography but not CMR and 19 vice versa. Upon reanalysis by the expert panel, aneurysms were initially missed on CMR in 16 patients (80%), largely because of interpretation error secondary to small aneurysms, with a mean aneurysm size of 0.82 ± 0.38 cm in these cases. Before secondary review by the expert panel, contrast echocardiography had sensitivity of 97% compared with 85% for CMR (P = .0198) and 64% for noncontrast echocardiography (P = .0001). After secondary review, contrast echocardiography had sensitivity of 98% compared with 67% for noncontrast echocardiography (P = .0001) and 97% for CMR (P = 1.00).
Conclusions
Contrast echocardiography has high sensitivity for detecting LV apical aneurysms and should be used routinely in the evaluation and risk stratification of patients with HCM.

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

J Am Soc Echocardiogr: 07 Aug 2021; epub ahead of print
Lee DZJ, Chan RH, Montazeri M, Hoss S, ... Nguyen ET, Rakowski H
J Am Soc Echocardiogr: 07 Aug 2021; epub ahead of print | PMID: 34375676
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Abstract

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

Li L, Colen TM, Jani V, Barnes BT, ... Danford DA, Kutty S
Background
The aims of this study were to investigate the dynamic changes in the vena contracta (VC) and proximal isovelocity surface area (PISA) through systole in patients with hypoplastic left heart syndrome and tricuspid regurgitation and to identify the stage of systole (early, mid, or late) in which VC and PISA radius are optimal.
Methods
Twenty-eight patients with hypoplastic left heart syndrome were prospectively studied using continuous two-dimensional (2D) and three-dimensional (3D) echocardiography. Two-dimensional VC width, 3D VC area, and PISA radii (2D and 3D) were measured frame by frame throughout systole. The maximal 2D VC width, 3D VC area, and PISA radii in the first, middle, and last thirds of systole were compared, and correlations were explored with 3D tricuspid annular areas, right atrial volumes, and right ventricular volumes.
Results
In all, 35 data sets that met inclusion criteria were analyzed. On frame-by-frame analysis, maximal 2D VC width and 3D VC area were found in the first third of systole in 17% and 20% of studies, in the second third in 34% and 31%, and in the final third in 49% and 49%. Similarly, the maximal 2D and 3D PISA radii were found in the first third of systole in 26% and 17% of studies, in the second third in 28% and 34%, and in the final third in 46% and 49%.
Conclusions
In hypoplastic left heart syndrome, detailed temporal analysis of tricuspid regurgitation-associated VC and PISA by 2D and 3D echocardiography reveals no reliable pattern predicting when in systole these parameters peak. Frame-by-frame measurement is necessary for identification of maximal VC and PISA radius on 2D and 3D color Doppler echocardiography because the severity of tricuspid regurgitation could be underestimated because of temporal variability in VC and PISA.

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

J Am Soc Echocardiogr: 30 Jul 2021; 34:877-886
Li L, Colen TM, Jani V, Barnes BT, ... Danford DA, Kutty S
J Am Soc Echocardiogr: 30 Jul 2021; 34:877-886 | PMID: 33753189
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Impact:

This program is still in alpha version.