Journal: J Am Soc Echocardiogr

Sorted by: date / impact
Abstract

Global Right Heart Assessment with Speckle-Tracking Imaging Improves the Risk Prediction of a Validated Scoring System in Pulmonary Arterial Hypertension.

Stolfo D, Albani S, Biondi F, De Luca A, ... Emdin M, Sinagra G
Background
Right ventricular (RV) function and right atrial (RA) remodeling are major determinants of outcome in pulmonary arterial hypertension (PAH). Strain echocardiography is emerging as a valuable approach for the study of RV and RA function. We sought to assess the incremental prognostic value of serial combined speckle-tracking examination of right chambers in newly diagnosed therapy-naïve PAH patients.
Methods
The study endpoint was a composite of all-cause mortality, hospitalizations due to worsening PAH, and initiation of parenteral prostanoids. Patients were assessed at baseline and at first revaluation after initiation of treatment. Right ventricular free-wall longitudinal strain (FWLS) and RA peak atrial longitudinal strain (PALS) were used as measures of RV and RA function.
Results
Eighty-three patients were included. Mean RV-FWLS and RA-PALS were -13.9% ± 6.1% and 23.1% ± 11.4%. The best performing prognostic score among the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension, French Pulmonary Hypertension Registry, and Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management (REVEAL) scores was the REVEAL (area under the curve = 0.79, P < .001). With the identified cutoffs, both RV-FWLS (hazard ratio for RV-FWLS < -13.2% = 0.366; 95% CI, 0.159-0.842; P = .018) and RA-PALS (hazard ratio for RA-PALS > 20% = 0.399; 95% CI, 0.176-0.905; P = .028) were independently associated with the primary outcome after correction for the REVEAL score. The combined assessment of RV-FWLS and RA-PALS in addition to the REVEAL score determined a net improvement in prediction of 0.439 (95% CI, 0.070-0.888, P = .04). At 5 months (interquartile range, 4-8) of follow-up, RV-FWLS and RA-PALS improved significantly only in patients free from the primary outcome (P < .001 and P = .001, respectively).
Conclusions
The combined assessment of RV-FWLS and RA-PALS determined an improvement in outcome prediction of validated prognostic risk scores and should be considered within the multiparametric evaluation of patients with PAH.

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

J Am Soc Echocardiogr: 30 Jul 2020; epub ahead of print
Stolfo D, Albani S, Biondi F, De Luca A, ... Emdin M, Sinagra G
J Am Soc Echocardiogr: 30 Jul 2020; epub ahead of print | PMID: 32747222
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Left Ventricular Diastolic Function in Healthy Adult Individuals: Results of the World Alliance Societies of Echocardiography Normal Values Study.

Miyoshi T, Addetia K, Citro R, Daimon M, ... Asch FM,
Background
The World Alliance Societies of Echocardiography (WASE) study was conducted to describe echocardiographic normal values in adults and to compare races and nationalities using a uniform acquisition and measurement protocol. This report focuses on left ventricular (LV) diastolic function.
Methods
WASE is an international, cross-sectional study. Participants were enrolled with equal distribution according to age and gender. Echocardiograms were analyzed in a core laboratory based on the latest American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Left ventricular diastolic function was assessed by E, E/A, e\' velocities, E/e\', left atrial volume index (LAVI), and tricuspid regurgitation velocity. Determination of LV diastolic function was made using the algorithm proposed by the guidelines.
Results
A total of 2,008 subjects from 15 countries were enrolled. The majority were of white or Asian race (42.8%, 41.8%, respectively). E and E/e\' were higher in female patients, while LAVI was similar in both genders. Consistent increase in E/e\' and decrease in E/A, E, and e\' were found as age increased. The upper limit of normal for LAVI was higher in WASE compared with the guidelines. The lower limits of normal for e\' were smaller in elder groups than those in the guidelines, while the upper limits of normal for E/e\' were below the guideline values. These findings suggest that the cutoff value for LAVI should be shifted upward and age-specific cutoff values for e\' should be considered. In WASE, <93.6% of patients were classified as normal LV diastolic function using the guidelines\' algorithm, and the proportion increased to 97.4% when applying the revised cutoff values for LAVI obtained in our study.
Conclusions
Guideline-recommended normal values for e\' velocities and LAVI should be reconsidered. The algorithm for the determination of LV diastolic function proposed by the guidelines is useful, but adjustments to LAVI could further improve it.

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

J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print
Miyoshi T, Addetia K, Citro R, Daimon M, ... Asch FM,
J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print | PMID: 32741597
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Diagnostic Accuracy of Fetal Echocardiography in Congenital Heart Disease.

Mozumdar N, Rowland J, Pan S, Rajagopal H, ... Srivastava S, Stern KWD
Background
The accuracy of fetal echocardiography (FE) is not well defined, and reporting of diagnostic discrepancies (DDs) is not standardized. The authors applied a categorization scheme developed by the American College of Cardiology Quality Metric Working Group and applied it to FE.
Methods
A retrospective single-center study was conducted of prenatally diagnosed major structural congenital heart disease, defined as expected need for intervention within the first year of life. DDs between pre- and postnatal findings were identified and categorized. Minor DDs had no clinical impact, moderate DDs had impact without harm, and severe DDs resulted in adverse events. Multivariate regression analysis was used to determine factors associated with discrepancy.
Results
From December 2008 to September 2017, 17,096 fetal echocardiograms were obtained, among which 222 fetuses with a median gestational age at first FE of 24 weeks were included. There were 30 DDs (13.5%), of which the majority were false negatives (56.7%). Most were minor or moderate in severity, with one severe DD. The majority were possibly preventable (90%), with the most common contributing factor being technical limitations (43.3%). The most common anatomic segment involved was the ventricular septum (23%), primarily missed septal defects. Comparing cases with DDs versus those without, those with DDs were more likely to have high anatomic complexity (16.7% vs 3.6%, P = .01), maternal comorbidities (40.0% vs 22.1%, P = .03), and a younger maternal age (median, 27 vs 30 years, P = .02). They were also more likely to have later gestation at initial FE (median, 29.5 vs 24 weeks, P = .003), to have fewer total fetal echocardiograms (median, 2 vs 3, P = .002), and to have a fellow as the initial sonographer (36.7% vs 16.7%, P = .03). There were no significant differences in maternal race/ethnicity, fetal comorbidities, and interpreting physician experience between cases with DDs and those without. On multivariate analysis, variables associated with DD included high anatomic complexity, maternal comorbidities, and fellow as initial imager. A greater number of fetal echocardiograms was associated with reduced DD.
Conclusions
FE had a DD rate of 13.5%, mostly minor and moderate in severity. Factors associated with DD included high anatomic complexity, maternal comorbidities, fellow as the initial sonographer, and fewer fetal echocardiograms. Strategies to reduce DD could include a regular secondary review and repeat FE, particularly when anatomic complexity is high.

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

J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print
Mozumdar N, Rowland J, Pan S, Rajagopal H, ... Srivastava S, Stern KWD
J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print | PMID: 32828627
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Nonapical Right Ventricular Pacing Is Associated with Less Tricuspid Valve Interference and Long-Term Progress of Tricuspid Regurgitation.

Yu YJ, Chen Y, Lau CP, Liu YX, ... Tse HF, Yiu KH
Background
Tricuspid regurgitation (TR) is a well-known complication after permanent pacemaker implantation. The aim of this study was to compare the degree of TR and the relationship of lead position across the tricuspid valve (TV) between patients with right ventricular apical (RVA) and non-RVA pacing determined by three-dimensional echocardiography.
Methods
Conventional and three-dimensional echocardiography was performed in 284 patients to determine the change in TR severity following permanent pacemaker implantation. Transvenous lead locations were based on fluoroscopic images. This was a retrospective study, and the selected pacing mode was not randomized.
Results
RVA pacing had more frequent severe TR (37.9% vs 25.7%, P = .03) compared with non-RVA pacing. Severe TR occurred in 9.7%, 12.6%, and 58.8% of patients when the lead passed through the middle, between the commissures, and impinging the TV leaflets, respectively. Non-RVA leads were more likely to be positioned in the middle of the TV (30.3% vs 12.1%, P < .01) and had the lowest chance of leaflet impingement (33.6% vs 51.5%, P < .01) compared with RVA leads. RVA pacing was associated with worsening of grade ≥2 TR severity compared with non-RVA pacing (42.4% vs 27.6%, P < .01). A TV lead passage angle of -15° to 15° minimized TR.
Conclusions
Pacing-induced TR is more prevalent with RVA than non-RVA pacing. Preferential lead impingement on the TV leaflet, as determined by TV lead passage angle, can explain the development and progression of pacing-induced TR.

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

J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print
Yu YJ, Chen Y, Lau CP, Liu YX, ... Tse HF, Yiu KH
J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print | PMID: 32828623
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 09 Sep 2020; epub ahead of print
Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V
J Am Soc Echocardiogr: 09 Sep 2020; epub ahead of print | PMID: 32921538
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Thellier N, Altes A, Appert L, Binda C, ... Tribouilloy C, Maréchaux S
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919856
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Fukui M, Niikura H, Sorajja P, Hashimoto G, ... Gössl M, Cavalcante JL
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919854
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981787
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 20 Sep 2020; epub ahead of print
Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 20 Sep 2020; epub ahead of print | PMID: 32972777
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981789
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The Prognostic Value of Exercise Echocardiography after Percutaneous Coronary Intervention.

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

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036819
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Usefulness of Noninvasive Myocardial Work to Predict Left Ventricular Recovery and Acute Complications after Acute Anterior Myocardial Infarction Treated by Percutaneous Coronary Intervention.

Meimoun P, Abdani S, Stracchi V, Elmkies F, ... Zemir H, Clerc J
Background
Predicting left ventricular recovery (LVR) after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. Our objective was to evaluate the usefulness of noninvasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LVR and in-hospital complications after STEMI.
Methods
Ninety-three patients with anterior STEMI (mean age, 59 ± 12 years) treated by percutaneous coronary intervention (PCI) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24-48 hours after PCI and a median of 92 days at follow-up. Myocardial work is derived from the strain-pressure relation, integrating in its calculation the noninvasive arterial pressure. Segmental LVR was defined as a normalization of wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) > 5% in patients with baseline LVEF ≤ 50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus.
Results
Segmental MW was impaired in infarct segments, more severely in nonrecovering versus recovering segments (P < .01). Furthermore, global constructive MW was significantly correlated with follow-up LVEF (r = 0.58) and global longitudinal strain (r = -0.67; all P < .01). Constructive MW was the best index to predict segmental (P < .01 vs MW index, MW efficiency, and wasted work) and global recovery (P < .05 vs global longitudinal strain) with an independent association (odds ratio = 1.17, 95% CI, 1.13-1.20, and odds ratio = 1.43, 95% CI, 1.18-1.68, respectively; all P < .001). Moreover, global constructive MW was more severely impaired in patients with in-hospital complications (n = 16; P < .01).
Conclusions
In patients with anterior STEMI treated by PCI, constructive MW is an independent predictor of segmental and global LVR and is significantly impaired in patients with in-hospital complications.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1180-1190
Meimoun P, Abdani S, Stracchi V, Elmkies F, ... Zemir H, Clerc J
J Am Soc Echocardiogr: 29 Sep 2020; 33:1180-1190 | PMID: 33010853
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Noninvasive Myocardial Work Indices 3 Months after ST-Segment Elevation Myocardial Infarction: Prevalence and Characteristics of Patients with Postinfarction Cardiac Remodeling.

Lustosa RP, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, ... Bax JJ, Delgado V
Background
Assessment of left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) is pivotal for patient management. Noninvasive myocardial work indices obtained from echocardiography-derived strain-pressure loops provide a new tool that permits characterization of LV mechanics. We aimed at characterizing myocardial work indices in patients with LV remodeling after STEMI versus patients without remodeling.
Methods
Six-hundred STEMI patients were retrospectively analyzed (456 men, mean age: 61 ± 11 years) and divided according to the presence of LV remodeling 3 months after the index admission (≥20% increase in LV end-diastolic volume). Noninvasive myocardial work indices were measured at 3 months after STEMI.
Results
LV remodeling was observed in 150 patients (25%) who showed more impaired global myocardial work indices compared with their counterparts: work index (1,708 ± 522 mm Hg% vs 1,979 ± 450 mm Hg%; P < .001), constructive work (1,941 ± 598 mm Hg% vs 2,272 ± 519 mm Hg%; P < .001), and work efficiency (92% [range 88%-96%] vs 95% [range 93%-96%]; P < .001). In addition, patients with LV remodeling had significantly increased wasted work (116 mm Hg% [range 73-184 mm Hg%] vs 91 mm Hg% [range 61-132 mm Hg%]; P < .001). The frequency of impaired global work index, constructive and work efficiency, and increased wasted work was significantly higher among patients with LV remodeling compared with their counterparts: 21.3%, 34.7%, 34.7%, and 14.0%, respectively, versus 5.3%, 9.6%, 8.9%, and 4.9%, respectively (P < .001).
Conclusions
At 3-month follow-up after STEMI, patients with LV remodeling revealed more impaired myocardial work indices compared with patients without LV remodeling. The prevalence of impaired myocardial work indices was higher among patients with LV remodeling compared with patients without.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1172-1179
Lustosa RP, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 29 Sep 2020; 33:1172-1179 | PMID: 32651125
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation.

Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
Background
The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal \"splay\" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign.
Methods
Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR.
Results
Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it.
Conclusions
The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1212-1219.e1
Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
J Am Soc Echocardiogr: 29 Sep 2020; 33:1212-1219.e1 | PMID: 32712051
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study.

Coisne A, Pontana F, Aghezzaf S, Mouton S, ... Modine T, Montaigne D
Background
Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening.
Methods
Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging.
Results
Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r = 0.88 and r = 0.92, respectively, P < .0001). Correlations were significant but lower for MA diameters (r = 0.68-0.72, P < .0001) and mitroaortic angle (r = 0.53, P = .0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15 cm for MA area (area under the curve [AUC] = 0.88-0.91, P < .0001), 128 to 139 mm for MA perimeter (AUC = 0.85-0.91, P < .0001), 35 to 39 mm for anteroposterior diameter (AUC = 0.79-0.84, P < .0001), and 37 to 42 mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, P < .0001).
Conclusions
Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1245-1252.e2
Coisne A, Pontana F, Aghezzaf S, Mouton S, ... Modine T, Montaigne D
J Am Soc Echocardiogr: 29 Sep 2020; 33:1245-1252.e2 | PMID: 32718722
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Effect of Short-Term L-Thyroxine Therapy on Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy.

Badran HM, Faheem N, Zidan A, Yacoub MH, Soltan G
Objective
Previous experimental studies have provided evidence of notable changes in thyroid hormone signaling that corresponds to alterations in myocardial function in animal models of heart failure (HF). The present study further explores whether oral thyroid hormone treatment can change left ventricular (LV) mechanics and functional status in patients with idiopathic dilated cardiomyopathy (IDCM) or not.
Methods
Sixty IDCM patients who were receiving conventional HF treatment were randomized to oral L-thyroxine (n = 40) or placebo (n = 20) for 3 months. Fifty-two (86.7%) of all IDCM patients were symptomatic, their mean age was 41 ± 12 years, and their ejection fraction was 32% ± 7%. At baseline, the two groups were comparable in clinical and echocardiographic variables. Vector velocity imaging was utilized to assess LV mechanics. Myocardial longitudinal peak systolic strain, systolic strain rate, early and late diastolic strain rate, circumferential strain, LV dyssynchrony, plasma tri-iodothyronine, thyroxine, and thyroid stimulating hormone levels were measured at baseline and 3 months after treatment.
Results
All patients receiving L-thyroxine significantly improved in functional status (New York Heart Association class; P < .001) and echocardiographic parameters including end-diastolic diameter (P < .001), end-systolic diameter (P < .001), mitral regurgitation severity reduction (P < .001), and increased ejection fraction (P < .001). Left ventricular mechanics showed marked improvement at segmental and global levels of both longitudinal and circumferential myocardial strain (P < .005) when compared with placebo group.
Conclusions
Short-term L-thyroxine therapy is well tolerated in IDCM patients. It improves cardiac mechanics and functional status, which might support the potential role of synthetic thyroid hormones in HF treatment.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1234-1244
Badran HM, Faheem N, Zidan A, Yacoub MH, Soltan G
J Am Soc Echocardiogr: 29 Sep 2020; 33:1234-1244 | PMID: 32792320
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036818
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Longitudinal Strain Reflects Ventriculoarterial Coupling Rather Than Mere Contractility in Rat Models of Hemodynamic Overload-Induced Heart Failure.

Ruppert M, Lakatos BK, Braun S, Tokodi M, ... Kovács A, Radovits T
Background
Longitudinal strain (LS) is a sensitive marker of systolic function. Recent findings suggest that both myocardial contractility and loading conditions determine LS. The aim of this study was to investigate whether LS reflects the connection of cardiac contractility to afterload (termed ventriculoarterial coupling [VAC]) rather than mere contractility in rat models of hemodynamic overload-induced heart failure (HF).
Methods
Pressure overload-induced HF was evoked by transverse aortic constriction (TAC; n = 14). Volume overload-induced HF was established by an aortocaval fistula (ACF; n = 12). Age-matched sham-operated animals served as controls for TAC (n = 14) and ACF (n = 12), respectively. Pressure-volume analysis was carried out to compute contractility (slope of end-systolic pressure-volume relationship [ESPVR]), afterload (arterial elastance [E]), and VAC (E/ESPVR). Preload was evaluated by meridional end-diastolic wall stress. Speckle-tracking echocardiography was performed to assess LS.
Results
The TAC group presented with maintained ESPVR, increased E, and enhanced meridional end-diastolic wall stress. In contrast, the ACF group was characterized by reduced ESPVR, decreased E, and enhanced meridional end-diastolic wall stress. VAC increased in both HF groups. Furthermore, LS was also impaired in both HF models (-5.9 ± 0.6% vs -12.9 ± 0.5%, TAC vs Sham [P < .001], and -11.7 ± 0.7% vs -13.5 ± 0.4%, ACF vs Sham[P = .048]). Statistical analysis revealed that strain parameters were determined predominantly by afterload in the TAC group and by contractility in the ACF group, while preload had a minor effect. In the entire study population, LS showed a correlation with VAC (R = 0.654, P < .001) but not with ESPVR (R = 0.058, P = .668).
Conclusions
Under pathophysiologic conditions when both contractility and afterload become altered, LS reflects VAC rather than mere contractility.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1264-1275.e4
Ruppert M, Lakatos BK, Braun S, Tokodi M, ... Kovács A, Radovits T
J Am Soc Echocardiogr: 29 Sep 2020; 33:1264-1275.e4 | PMID: 32778499
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 13 Oct 2020; epub ahead of print
Guzzetti E, Tastet L, Annabi MS, Capoulade R, ... Clavel MA, Pibarot P
J Am Soc Echocardiogr: 13 Oct 2020; epub ahead of print | PMID: 33067075
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 09 Oct 2020; epub ahead of print
Barakat MF, Chehab O, Kaura A, Sunderland N, ... Scott PA, Okonko DO
J Am Soc Echocardiogr: 09 Oct 2020; epub ahead of print | PMID: 33051107
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Right Atrial Conduit Phase Emptying Predicts Risk of Adverse Events in Pediatric Pulmonary Arterial Hypertension.

Frank BS, Schafer M, Thomas TM, Haxel C, Ivy DD, Jone PN
Background
Idiopathic pulmonary arterial hypertension (PAH) is a severe disease associated with a 20% 5-year mortality, often due to right heart failure. Recent studies suggest that compensatory changes in right atrial (RA) function may precede other clinical and echocardiographic evidence of right ventricular dysfunction. No prior prospective study has evaluated the role of RA emptying pattern as a prognostic marker of adverse clinical events in pediatric PAH.
Objective
To demonstrate whether RA fractional emptying indices will prospectively predict risk of adverse clinical outcomes in pediatric PAH patients.
Methods
Single-center, prospective cohort analysis of 41 patients with idiopathic or heritable PAH and 1:1 age and sex-matched controls with normal echo and electrocardiogram. Right atrial area (RAA) was measured just prior to tricuspid valve opening (RAAmax), at electrical p wave (RAAp), and just after tricuspid valve closing (RAAmin). Right atrial conduit fraction percent (RA cF%) was defined as the percentage of total RAA change happening prior to the electrical p wave = (RAAmax - RAAp)/(RAAmax - RAAmin) ∗ 100. Clinical worsening was analyzed with a predefined composite adverse event outcome.
Results
RA measurements were technically feasible in all study participants. The PAH patients (median age 11.9 years) had decreased RA cF% compared with controls (P < .0001), and PAH subjects with lower RA cF% demonstrated higher right ventricular systolic (R = -0.49, P = .019) and end-diastolic (R = -0.52, P = .012) pressure than those with higher RA cF%. Sixteen subjects had a clinical event. Right atrial cF% (hazard ratio = 0.09; P < .001) was highly prognostic for risk of adverse clinical event with area under the curve = 0.90 on receiver operating characteristic curve analysis (median 3.2-year follow-up).
Conclusions
Right atrial conduit phase emptying is significantly altered in pediatric PAH. Within the PAH population, decreased RA cF% was prognostic for risk of clinical worsening. The combination of accuracy and ease of measurement could make RA cF% a clinically useful, noninvasive biomarker of early right heart failure and risk of disease progression in pediatric PAH.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:1006-1013
Frank BS, Schafer M, Thomas TM, Haxel C, Ivy DD, Jone PN
J Am Soc Echocardiogr: 30 Jul 2020; 33:1006-1013 | PMID: 32336608
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Correlates and Long-Term Implications of Left Ventricular Mechanical Dispersion by Two-Dimensional Speckle-Tracking Echocardiography in Patients with ST-Segment Elevation Myocardial Infarction.

Abou R, Goedemans L, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
Background
Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients.
Methods
A total of 1,000 STEMI patients (77% male, 60 ± 12 years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48 hours following the index infarction. Patients were followed for the occurrence of all-cause mortality.
Results
After a median follow-up of 117 months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43% ± 10% vs 48% ± 9%; P < .001) and global longitudinal strain (-12.0% ± 3.5% vs -14.2% ± 3.5%; P = .001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P < .001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow < 2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio = 1.012; 95% CI, 1.005-1.018; P = .001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters.
Conclusions
In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:964-972
Abou R, Goedemans L, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 30 Jul 2020; 33:964-972 | PMID: 32381361
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Value of Right Ventricular Two-Dimensional and Three-Dimensional Speckle-Tracking Strain in Pulmonary Arterial Hypertension: Superiority of Longitudinal Strain over Circumferential and Radial Strain.

Li Y, Wang T, Haines P, Li M, ... Lv Q, Xie M
Background
Right ventricular (RV) dysfunction is a predictor of adverse outcomes in patients with pulmonary arterial hypertension (PAH). Three-dimensional (3D) speckle-tracking echocardiography (STE) has been increasingly used to quantify RV function. However, the strain parameters evaluated by two-dimensional (2D) STE and 3D STE, which provide the most valuable clinical information, remain unknown. The purpose of our study was to investigate whether RV longitudinal strain (LS) provided a superior estimation of RV systolic performance and prognostic information compared with other strain vectors.
Methods
We prospectively studied 54 treatment-naïve patients with PAH and 35 normal controls. Pulmonary artery systolic pressure classified patients with PAH into three subgroups. Patients with PAH underwent echocardiography, cardiac magnetic resonance (CMR) imaging, 6-minute walking tests, and right-sided cardiac catheterization before and six months after vasodilator therapy. The 2D LS, 3D LS, circumferential strain (CS), and radial strain (RS) of RV free wall were calculated by 2D and 3D STE. RV ejection fraction (RVEF) was obtained from CMR. The patients were followed for a predefined endpoint of PAH-related hospitalization and death.
Results
Our findings revealed that 2D and 3D LS showed significant reduction in mild PAH patients, whereas CS and RS were decreased in moderate and severe PAH patients. Right ventricular 3D LS had a similar correlation with CMR RVEF and hemodynamic parameters as 2D LS and the other strain vectors. The 2D and 3D LS improved 6 months after vasodilator therapy (P < .001 for both). After a median follow-up of 28 months, 20 patients had endpoint events. Receiver operating characteristic curve analysis demonstrated that RV 3D LS displayed a similar diagnostic performance for detecting adverse cardiac events as 2D LS (area under the curve: 0.84 vs 0.76, P = .11). Separate multivariable Cox analysis showed that RV 2D LS (hazard ratio [HR] = 1.19; 95% CI, 1.03~1.45; P = .01) and 3D LS (HR = 1.28; 95% CI, 1.08~1.52; P = .005) were significant predictors of adverse outcomes.
Conclusions
Patients with PAH show reduced RV strain. Two-dimensional and 3D LS can track clinical improvement following vasodilator therapy and provide valuable prognostic information.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:985-994.e1
Li Y, Wang T, Haines P, Li M, ... Lv Q, Xie M
J Am Soc Echocardiogr: 30 Jul 2020; 33:985-994.e1 | PMID: 32532643
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Contrast-Enhanced Echocardiographic Measurement of Left Ventricular Wall Thickness in Hypertrophic Cardiomyopathy: Comparison with Standard Echocardiography and Cardiac Magnetic Resonance.

Urbano-Moral JA, Gonzalez-Gonzalez AM, Maldonado G, Gutierrez-Garcia-Moreno L, ... Rodriguez-Palomares JF, Evangelista-Masip A
Background
Left ventricular wall thickness (LVWT) measurement is key in the diagnostic and prognostic assessment of hypertrophic cardiomyopathy (HCM). Recent investigations have highlighted discrepancies in LVWT by cardiac magnetic resonance (CMR) and standard echocardiography (S-Echo) in this condition. The aim of this study was to elucidate the role of contrast-enhanced echocardiography (C-Echo) to optimize LVWT measurement in patients with HCM.
Methods
Fifty patients with HCM were prospectively enrolled, undergoing S-Echo, C-Echo, and CMR. Blinded LVWT measurements were performed according to a 16-segment left ventricular model using all three imaging techniques. Agreement between both echocardiographic modalities and CMR (as the reference technique) at the segmental level was tested using Bland-Altman analyses. Reproducibility on segmental measurements by S-Echo and C-Echo was also investigated.
Results
Patients\' mean age was 47 ± 21 years, and 35 (70%) were men. Maximal mean LVWT by S-Echo (20.1 ± 3.8 mm) was greater than the values derived using C-Echo (17.6 ± 4.0 mm, P < .01) and CMR (17.7 ± 4.5 mm, P < .01), with no statistically significant difference between the latter two. Segmental Bland-Altman models demonstrated globally smaller bias and narrower 95% limits of agreement for C-Echo compared with S-Echo. Across all left ventricular segments, LVWT by C-Echo was 2.4 mm lower (range, 1.0-2.5 mm) than that derived by S-Echo, which accounted for a 25% intertechnique difference. Regarding maximal LVWT, the mean absolute difference between C-Echo and S-Echo was 3.0 ± 1.9 mm (range, 0.0-7.9 mm), which represented a 15% intertechnique change. Data analyses demonstrated globally less intra- and interobserver variability in segmental LVWT derived from C-Echo compared with S-Echo.
Conclusions
C-Echo rendered LVWT measurements closer to those derived by the reference technique (CMR) and improved reproducibility compared with S-Echo. C-Echo represents a suitable tool for LVWT measurement in patients with HCM as an alternative to CMR whenever this is not available or possible.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1106-1115
Urbano-Moral JA, Gonzalez-Gonzalez AM, Maldonado G, Gutierrez-Garcia-Moreno L, ... Rodriguez-Palomares JF, Evangelista-Masip A
J Am Soc Echocardiogr: 30 Aug 2020; 33:1106-1115 | PMID: 32564979
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Estimation of Stroke Volume and Aortic Valve Area in Patients with Aortic Stenosis: A Comparison of Echocardiography versus Cardiovascular Magnetic Resonance.

Guzzetti E, Capoulade R, Tastet L, Garcia J, ... Clavel MA, Pibarot P
Background
In aortic stenosis, accurate measurement of left ventricular stroke volume (SV) is essential for the calculation of aortic valve area (AVA) and the assessment of flow status. Current American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines suggest that measurements of left ventricular outflow tract diameter (LVOTd) at different levels (at the annulus vs 5 or 10 mm below) yield similar measures of SV and AVA. The aim of this study was to assess the effect of the location of LVOTd measurement on the accuracy of SV and AVA measured on transthoracic echocardiography (TTE) compared with cardiovascular magnetic resonance (CMR).
Methods
One hundred six patients with aortic stenosis underwent both TTE and CMR. SV was estimated on TTE using the continuity equation with LVOTd measurements at four locations: at the annulus and 2, 5, and 10 mm below annulus. SV was also determined on CMR using phase contrast acquired in the aorta (SV), and a hybrid AVA was calculated by dividing SV by the transthoracic echocardiographic Doppler aortic velocity-time integral. Comparison between methods was made using Bland-Altman analysis.
Results
Compared with the referent method of phase-contrast CMR for the estimation of SV and AVA (SV 83 ± 16 mL, AVA 1.27 ± 0.35 cm), the best agreement was obtained by measuring LVOTd at the annulus or 2 mm below (P = NS), whereas measuring 5 and 10 mm below the annulus resulted in significant underestimation of SV and AVA by up to 15.9 ± 17.3 mL and 0.24 ± 0.28 cm, respectively (P < .01 for all). Accuracy for classification of low flow was best at the annulus (86%) and 2 mm below (82%), whereas measuring 5 and 10 mm below the annulus significantly underperformed (69% and 61%, respectively, P < .001).
Conclusions
Measuring LVOTd at the annulus or very close to it provides the most accurate measures of SV and AVA, whereas measuring LVOTd 5 or 10 mm below significantly underestimates these parameters and leads to significant overestimation of the severity of aortic stenosis and prevalence of low-flow status.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:953-963.e5
Guzzetti E, Capoulade R, Tastet L, Garcia J, ... Clavel MA, Pibarot P
J Am Soc Echocardiogr: 30 Jul 2020; 33:953-963.e5 | PMID: 32580897
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Poor Survival with Impaired Valvular Hemodynamics After Aortic Valve Replacement: The National Echo Database Australia Study.

Playford D, Stewart S, Celermajer D, Prior D, ... Strange G,
Background
There are limited data to describe the relationship between the transvalvular gradient and mortality among patients who undergo aortic valve replacement.
Methods
Using the National Echo Database Australia, valvular hemodynamics were characterized in 3,943 men (mean age, 62 ± 18 years) and 2,107 women (mean age, 62 ± 19 years) who underwent aortic valve replacement (median follow-up duration, 770 days; interquartile range, 381-1,584 days). The degree of impaired valvular hemodynamics (IVH) was categorized as mild (mean gradient 10.0-19.9 mm Hg, peak velocity 2.0-2.9 m/sec), moderate (mean gradient 20.0-39.9 mm Hg, peak velocity 3.0-3.9 m/sec), or severe (mean gradient ≥ 40.0 mm Hg, peak velocity ≥ 4 m/sec or effective orifice area < 0.8 cm).
Results
Overall, 2,175 (36.0%), 2,598 (42.9%), 698 (11.5%), and 579 (9.6%) patients had no, mild, moderate, and severe IVH, respectively. Those with residual moderate or severe IVH had 5-year mortality of 45.5% and 57.3%, respectively, and higher adjusted long-term all-cause mortality (adjusted hazard ratios, 1.44 and 2.02; P < .001) compared with \"no IVH.\" Patients with mild IVH had similar mortality rates to those without IVH. A mortality threshold was evident above a mean transvalvular gradient >22.5 mm Hg after adjusting for age, sex, stroke volume index, aortic regurgitation, and effective orifice area.
Conclusions
After aortic valve replacement, most patients displayed an acceptable aortic valve hemodynamic profile. Moderate to severe IVH, however, was associated with poor long-term survival, with a threshold for increased mortality similar to that of native valvular aortic stenosis evident.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1077-1086.e1
Playford D, Stewart S, Celermajer D, Prior D, ... Strange G,
J Am Soc Echocardiogr: 30 Aug 2020; 33:1077-1086.e1 | PMID: 32593505
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Left Ventricular Systolic Function in Patients with Systemic Lupus Erythematosus and Its Association with Cardiovascular Events.

Gegenava T, Gegenava M, Steup-Beekman GM, Huizinga TWJ, ... Delgado V, Marsan NA
Background
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with potential cardiovascular involvement. The aim of this study was to assess left ventricular (LV) systolic function in a large cohort of patients with SLE using standard echocardiographic measurements and global longitudinal strain (GLS) by two-dimensional speckle-tracking analysis. Furthermore, the association between echocardiographic parameters and the occurrence of cardiovascular events was assessed.
Methods
A total of 102 patients with SLE (88% women; mean age, 43 ± 14 years) undergoing a dedicated multidisciplinary assessment were analyzed, including echocardiography, at the time of their first visit. A control group consisted of 50 age- and sex-matched healthy subjects.
Results
Compared with control subjects, patients with SLE showed impaired LV systolic function on the basis of LV ejection fraction (51 ± 6% vs 62 ± 6%, P < .001) and by LV GLS (-15 ± 3% vs -19 ± 2%, P < .001). During a median follow-up period of 2 years (interquartile range, 1-6 years), 38 patients (37%) developed cardiovascular events. Kaplan-Meier survival curves showed that patients with SLE with more impaired LV GLS (on the basis of the median value of -15%) experienced higher cumulative rates of cardiovascular events compared with those with less impaired LV GLS (χ = 8.292, log-rank P = .004). On multivariate Cox regression analysis, LV GLS demonstrated an independent association with cardiovascular events (hazard ratio, 2.171; 95% CI, 1.015-4.642; P = .046), whereas LV ejection fraction was not significantly associated with the outcome.
Conclusions
In patients with SLE, LV systolic function as measured by LV GLS is significantly impaired and associated with cardiovascular events, potentially representing a new tool to improve risk stratification in these patients.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1116-1122
Gegenava T, Gegenava M, Steup-Beekman GM, Huizinga TWJ, ... Delgado V, Marsan NA
J Am Soc Echocardiogr: 30 Aug 2020; 33:1116-1122 | PMID: 32622589
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Myocardial Scar by Pulse-Cancellation Echocardiography Is Independently Associated with Appropriate Defibrillator Intervention for Primary Prevention after Myocardial Infarction.

Gaibazzi N, Suma S, Lorenzoni V, Sartorio D, ... Siniscalchi C, Garibaldi S
Background
Myocardial scar burden impacts prognosis in patients with coronary artery disease who have experienced a myocardial infarction (MI). This has been demonstrated by late gadolinium enhancement cardiac magnetic resonance. Clinical experience with echocardiography suggests that the reflected ultrasound signal is enhanced in infarcted myocardial segments. Scar imaging with an ultrasound multipulse scheme (eScar) has been preliminarily validated in prior studies.
Objective
To assess whether scar burden, as detected by eScar, is associated with implantable cardioverter-defibrillator (ICD) shocks in post-MI patients.
Methods
We retrospectively selected 50 post-MI patients with an ejection fraction <35% who received an ICD for primary prevention and subsequently had at least one appropriate shock (cases). These were compared with 50 post-MI patients, matched for clinical variables and ejection fraction, who never experienced an appropriate defibrillator shock (controls). Subjects were assessed with the eScar technique at the time of implantation or during follow-up.
Results
An eScar was present in ≥1 segment in 40 of 50 (80%) cases vs 26 of 50 (52%) controls and was associated with appropriate ICD shocks (P = .004). Receiver operating characteristic curve analysis, using a threshold of ≥3 segments by eScar, showed an area under the curve (AUC) of 0.715. On models including clinical and echocardiographic variables, eScar remained significantly associated with ICD shocks (P = .050 or P = .033 depending on the model). Adding eScar to a multivariate logistic regression model including indexed left ventricular end-systolic volume led to an increase in AUC from 0.734 to 0.782 (P = .049), while substituting indexed left ventricular end-diastolic volume for indexed left ventricular end-systolic volume resulted in a nonsignificant increase in AUC from 0.747 to 0.785 (P = .098).
Conclusions
Presence and extent of eScar were independently associated with appropriate ICD shocks in this study of patients with prior MI and reduced ejection fraction. However, the addition of eScar assessment to the clinical multivariable model that included also indexed left ventricular end-diastolic volume did not provide significant incremental value.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1123-1131
Gaibazzi N, Suma S, Lorenzoni V, Sartorio D, ... Siniscalchi C, Garibaldi S
J Am Soc Echocardiogr: 30 Aug 2020; 33:1123-1131 | PMID: 32622588
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Refining Severe Tricuspid Regurgitation Definition by Echocardiography with a New Outcomes-Based \"Massive\" Grade.

Kebed KY, Addetia K, Henry M, Yamat M, ... Mor-Avi V, Lang RM
Background
Current echocardiographic guidelines recommend that tricuspid regurgitation (TR) severity be graded in three categories, following assessment of specific parameters. Findings from recent trials have shown that the severity of TR frequently far exceeds the current definition of severe. We postulated that a grading approach that emphasizes outcomes could be useful to identify patients with severe TR at increased risk of mortality.
Methods
We identified 284 patients with echocardiograms demonstrating severe functional TR, defined as vena contracta (VC) ≥ 0.7 cm. Demographics and mortality data were obtained from the medical records. Patients were divided into study (n = 122 patients with three-dimensional images) and validation (n = 162) cohorts. The VC was measured in both the right ventricular (RV) inflow and apical four-chamber views and averaged. For the study cohort, tricuspid annular, RV end-diastolic (basal, mid, long axis) dimensions, tricuspid leaflet tenting height and area, RV free-wall longitudinal strain, and RV volumes were measured from two- and three-dimensional data sets. A K-partition algorithm was used in the study cohort to derive a mortality-related cutoff VC value, above which TR was termed \"massive.\" The ability of this VC cutoff to identify patients at greater mortality risk was then tested in the validation cohort using Kaplan-Meier survival analysis.
Results
In the study cohort, VC > 0.92 cm (massive TR) was optimally associated with worse survival. Tricuspid annular and RV size were larger in the massive group (P < .05), while there were no significant differences in demographics between the TR groups. Importantly, in the independent validation cohort, the above VC cutoff also correlated with increased mortality in the massive group (log-rank P < .05).
Conclusions
Among patients traditionally defined as having severe TR, a subset exists with massive TR, resulting in greater adverse RV remodeling and increased mortality. These patients may derive the greatest benefit from emerging percutaneous therapies.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1087-1094
Kebed KY, Addetia K, Henry M, Yamat M, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 30 Aug 2020; 33:1087-1094 | PMID: 32651124
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 30 Jul 2020; epub ahead of print
Saraiva RM, Pacheco NP, Pereira TOJS, Costa AR, ... Mediano MFF, Veloso HH
J Am Soc Echocardiogr: 30 Jul 2020; epub ahead of print | PMID: 32747223
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print
Colan SD, Sleeper LA
J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print | PMID: 32741595
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Evaluation of Left Atrial Size and Function: Relevance for Clinical Practice.

Thomas L, Muraru D, Popescu BA, Sitges M, ... Donal E, Badano LP

Left atrial (LA) structural and functional evaluation have recently emerged as powerful biomarkers for adverse events in a variety of cardiovascular conditions. Moreover, noninvasive evaluation of LA pressure has gained importance in the characterization of the hemodynamic profile of patients. This review describes the methodology, benefits and pitfalls of measuring LA size and function by echocardiography and provides a brief overview of the prognostic utility of newer echocardiographic metrics of LA geometry and function (i.e., three-dimensional volumes, longitudinal strain, and phasic function parameters).

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:934-952
Thomas L, Muraru D, Popescu BA, Sitges M, ... Donal E, Badano LP
J Am Soc Echocardiogr: 30 Jul 2020; 33:934-952 | PMID: 32762920
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print
Rato J, Vigneswaran TV, Simpson JM
J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print | PMID: 32828625
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print
Truong VT, Mazur W, Broderick J, Egnaczyk GF, ... Bartone C, Chung ES
J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print | PMID: 32828622
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 28 Aug 2020; epub ahead of print
Hayek A, Derimay F, Green L, Rosset M, ... Rioufol G, Finet G
J Am Soc Echocardiogr: 28 Aug 2020; epub ahead of print | PMID: 32868157
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Right Ventricular Global Longitudinal Strain and Outcomes in Heart Failure with Preserved Ejection Fraction.

Lejeune S, Roy C, Ciocea V, Slimani A, ... Gerber BL, Pouleur AC
Background
Right ventricular (RV) strain has emerged as an accurate tool for RV function assessment and is a powerful predictor of survival in patients with heart failure with reduced ejection fraction. However, its prognostic impact in patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. The aim of this study was to compare the prognostic value of RV global longitudinal strain (RVGLS) by two-dimensional speckle-tracking echocardiographic (STE) imaging in patients with HFpEF against conventional RV function parameters.
Methods
Patients with HFpEF were prospectively recruited, and 149 of 183 (81%) with analyzable STE RVGLS images constituted the final study population (mean age, 78 ± 9 years; 61% women), compared with 28 control subjects of similar age and sex. All control subjects and 120 patients also underwent cardiac magnetic resonance imaging. Patients were followed up for a primary end point of all-cause mortality and first heart failure hospitalization, and Cox regression analysis was performed.
Results
Mean STE RVGLS was significantly altered in patients with HFpEF compared with control subjects (-21.7 ± 4.9% vs -25.9 ± 4.2%, P < .001). STE RVGLS correlated well with RV ejection fraction by cardiac magnetic resonance (r = -0.617, P < .001). Twenty-eight patients with HFpEF (19%) had impaired STE RVGLS (>-17.5%). During a mean follow-up period of 30 ± 9 months, 91 patients with HFpEF (62%) reached the primary end point. A baseline model was created using independent predictors of the primary end point: New York Heart Association functional class III or IV, hemoglobin level, estimated glomerular filtration rate, and the presence of moderate or severe tricuspid regurgitation. Impaired STE RVGLS provided significant additional prognostic value over this model (χ to enter = 7.85, P = .005). Impaired tricuspid annular plane systolic excursion and fractional area change, however, did not.
Conclusions
In patients with HFpEF, impaired RVGLS has strong prognostic value. STE RVGLS should be considered for systematic evaluation of RV function to identify patients at high risk for adverse events.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:973-984.e2
Lejeune S, Roy C, Ciocea V, Slimani A, ... Gerber BL, Pouleur AC
J Am Soc Echocardiogr: 30 Jul 2020; 33:973-984.e2 | PMID: 32387031
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Fetal Speckle-Tracking: Impact of Angle of Insonation and Frame Rate on Global Longitudinal Strain.

Semmler J, Day TG, Georgiopoulos G, Garcia-Gonzalez C, ... Charakida M, Simpson JM
Background
There is a growing body of research on fetal speckle-tracking echocardiography because it is considered to be an angle-independent modality. The primary aim of this study was to investigate whether angle of insonation and acquisition frame rate (FR) influence left ventricular endocardial global longitudinal peak strain (GLS) in the fetus.
Methods
Four-chamber views of 122 healthy fetuses were studied at three different angles of insonation (apex up/down, apex oblique, and apex perpendicular) at high and low acoustic FRs. GLS was calculated, and a linear mixed-model analysis was used for analysis. Six hundred fifty-six fetal echocardiographic clips were analyzed (288 in the second trimester, at a median gestation of 21 weeks [interquartile range (IQR), 1 week], and 368 in the third trimester, at a median gestation of 36 weeks [IQR, 2 weeks]).
Results
Angle of insonation and FRs were significant determinants of GLS. Ventricular septum perpendicular to the ultrasound beam was associated with higher (more negative) GLS compared with apex up/down (at high FR: -21.8% vs -19.7%, P < .001; at low FR: -24.1% vs -21.4%, P < .001). Higher frames per second (FPS; median 149 FPS [IQR, 33 FPS] = 61 frames per cycle [FPC] [IQR, 17 FPC]) compared with lower FPS (median 51 FPS [IQR, 15 FPS] = 22 FPC [IQR, 7 FPC]) at the same insonation angle resulted in lower GLS (apex up/down: -19.7% vs -21.4%, P < .001; apex oblique: -21.2% vs -22.7%, P < .001; apex perpendicular: -21.8% vs -24.1%, P < .001).
Conclusions
The present findings show that insonation angle and FR influence GLS significantly. These factors need to be considered when comparing studies with different acquisition protocols, when establishing normative values, and when interpreting pathology. Speckle-tracking echocardiography cannot be considered an angle-independent modality during fetal life.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1141-1146.e2
Semmler J, Day TG, Georgiopoulos G, Garcia-Gonzalez C, ... Charakida M, Simpson JM
J Am Soc Echocardiogr: 30 Aug 2020; 33:1141-1146.e2 | PMID: 32423727
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

New Comprehensive Reference Values for Arterial Vascular Parameters in Children.

Torigoe T, Dallaire F, Slorach C, Cardinal MP, ... Mertens L, Jaeggi E
Background
Noninvasive measurements of vascular parameters can be used for the detection and risk stratification of cardiovascular diseases. Most vascular parameters are influenced by age and body size, but pediatric reference values are scarce and limited to a few parameters. The aim of this study was to develop pediatric reference values and Z score equations for a comprehensive set of vascular parameters.
Methods
A total of 292 healthy subjects aged 0 to 18 years were prospectively recruited. Stiffness index β, pressure-strain elastic modulus, common carotid intima-media thickness, brachial flow-mediated dilation, radial augmentation index, central and right arm peripheral artery pulse-wave velocities, and pulse-wave velocity ratio were assessed. Normalization for age and anthropometric variables was performed using parametric multivariate regression modeling. Z scores were assessed for heteroscedasticity, residual association with age and body size, and distribution.
Results
Multivariate regression models with various combinations of height, weight, and age were used to obtain Z scores that were independent of age and body size. There was no residual association between Z scores and body size, age, or body mass index. There was no significant departure from the normal distribution.
Conclusions
The authors present reference values and Z score equations for a comprehensive set of vascular parameters during childhood. Further studies are necessary to assess their usefulness in detecting the vascular signs of subclinical atherosclerosis and chronic diseases, including congenital heart disease.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:1014-1022.e4
Torigoe T, Dallaire F, Slorach C, Cardinal MP, ... Mertens L, Jaeggi E
J Am Soc Echocardiogr: 30 Jul 2020; 33:1014-1022.e4 | PMID: 32444330
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Flow Augmentation in the Myocardium by Ultrasound Cavitation of Microbubbles: Role of Shear-Mediated Purinergic Signaling.

Moccetti F, Belcik T, Latifi Y, Xie A, ... Huke S, Lindner JR
Background
Ultrasound-mediated cavitation of microbubble contrast agents produces high intravascular shear. We hypothesized that microbubble cavitation increases myocardial microvascular perfusion through shear-dependent purinergic pathways downstream from ATP release that is immediate and sustained through cellular ATP channels such as Pannexin-1.
Methods
Quantitative myocardial contrast echocardiography perfusion imaging and in vivo optical imaging of ATP was performed in wild-type and Pannexin-1-deficient (Panx1) mice before and 5 and 30 minutes after 10 minutes of ultrasound-mediated (1.3 MHz, mechanical index 1.3) myocardial microbubble cavitation. Flow augmentation in a preclinical model closer to humans was evaluated in rhesus macaques undergoing myocardial contrast echocardiography perfusion imaging after high-power cavitation in the apical four-chamber plane for 10 minutes.
Results
Microbubble cavitation in wild-type mice (n = 7) increased myocardial perfusion by 64% ± 25% at 5 minutes and 95% ± 55% at 30 minutes compared with baseline (P < .05). In Panx1 mice (n = 5), perfusion increased by 28% ± 26% at 5 minutes (P = .04) but returned to baseline at 30 minutes. Myocardial ATP signal in wild-type (n = 7) mice undergoing cavitation compared with sham-treated controls (n = 3) was 450-fold higher at 5 minutes and 90-fold higher at 30 minutes after cavitation (P < .001). The ATP signal in Panx1 mice (n = 4) was consistently 10-fold lower than that in wild-type mice and was similar to sham controls at 30 minutes. In macaques (n = 8), myocardial perfusion increased twofold in the cavitation-exposed four-chamber plane, similar in degree to that produced by adenosine, but did not increase in the control two-chamber plane.
Conclusions
Cavitation of microbubbles in the myocardial microcirculation produces an immediate release of ATP, likely from cell microporation, as well as sustained release, which is channel dependent and responsible for persistent flow augmentation. These findings provide mechanistic insight by which cavitation improves perfusion and reduces infarct size in patients with myocardial infarction.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:1023-1031.e2
Moccetti F, Belcik T, Latifi Y, Xie A, ... Huke S, Lindner JR
J Am Soc Echocardiogr: 30 Jul 2020; 33:1023-1031.e2 | PMID: 32532642
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Artificial Intelligence and Echocardiography: A Primer for Cardiac Sonographers.

Davis A, Billick K, Horton K, Jankowski M, ... Palma R, Adams DB

Artificial intelligence (AI) is emerging as a key component in diagnostic medical imaging, including echocardiography. AI with deep learning has already been used with automated view labeling, measurements, and interpretation. As the development and use of AI in echocardiography increase, potential concerns may be raised by cardiac sonographers and the profession. This report, from a sonographer\'s perspective, focuses on defining AI, the basics of the technology, identifying some current applications of AI, and how the use of AI may improve patient care in the future.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1061-1066
Davis A, Billick K, Horton K, Jankowski M, ... Palma R, Adams DB
J Am Soc Echocardiogr: 30 Aug 2020; 33:1061-1066 | PMID: 32536431
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Geometry of Tricuspid Valve Apparatus in Patients with Mitral Regurgitation due to Fibroelastic Deficiency versus Barlow Disease: A Real-Time Three-dimensional Transesophageal Echocardiography Study.

Hirasawa K, Izumo M, Umemoto T, Suzuki K, ... Hirao K, Akashi YJ
Background
Tricuspid valve (TV) geometry gained attention when the prognostic significance of tricuspid regurgitation (TR) was determined. However, the TV geometric characteristics in Barlow disease (BD) have not been elucidated. This study aimed to clarify the difference in TV morphology between BD and fibroelastic deficiency (FED) and the effect of its geometry on residual TR after tricuspid annuloplasty (TAP) using three-dimensional (3D) transesophageal echocardiography.
Methods
Based on the mitral valve (MV) morphology defined by 3D transesophageal echocardiography, 106 patients with degenerative MV disease were classified into BD (n = 42) and FED (n = 64). Three-dimensional images of the TV were analyzed using a quantification software to compare the geometrical parameters. Among them, 35 patients (17 with BD and 18 with FED) underwent concomitant TAP during MV surgery, and the residual TR after TAP was evaluated within 1 month.
Results
TV annulus area, billowing height, and billowing volume were greater in BD than in FED (10.8 ± 2.9 vs 9.2 ± 2.4 cm, 4.6 ± 1.6 vs 2.3 ± 1.1 mm, and 1.3 ± 0.8 vs 0.3 ± 0.3 mL; all P < .01). In contrast, TV tenting height and tenting volume were smaller in BD than in FED (2.6 ± 1.5 vs 4.4 ± 2.4 mm and 0.3 ± 0.4 vs 0.9 ± 1.0 mL; both P < .01). These morphologic differences in TV were similar to those in MV. There was a strong correlation between MV billowing volume and TV billowing volumes (R = 0.83, P < .01). The prevalence of significant residual TR after TAP was greater in BD than in FED (35% vs 0%, P < .01). Moderate correlations between TV billowing height and volume and residual TR after TAP were observed (R = 0.47 and 0.49, respectively, both P < .01).
Conclusions
Patients with BD exhibited larger TV annulus area and billowing than FED patients. These results suggest that degenerative changes in the TV apparatus in BD patients are similar to that seen in the MV apparatus. These findings should be taken into consideration when a TV surgery is required.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1095-1105
Hirasawa K, Izumo M, Umemoto T, Suzuki K, ... Hirao K, Akashi YJ
J Am Soc Echocardiogr: 30 Aug 2020; 33:1095-1105 | PMID: 32561111
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Noninvasive Myocardial Work Index: Characterizing the Normal and Ischemic Response to Exercise.

Borrie A, Goggin C, Ershad S, Robinson W, Sasse A
Background
Myocardial work index (MWI) and work efficiency are new parameters for assessing left ventricular function. We aim to characterize the normal response to exercise in a mixed population and determine whether MWI can identify patients with inducible ischemia.
Methods
Patients were retrospectively enrolled from an existing database of exercise stress echocardiography. Inclusion criteria were a clinical indication of possible ischemia and technical suitability to calculate MWI. Exclusion criteria were abnormal baseline left ventricular function or inadequate image quality. Echocardiograms positive for ischemia were defined by independent visual assessment and compared with angiographic findings where available. Myocardial work index was determined using a proprietary algorithm and efficiency calculated as constructive work divided by the sum of constructive and wasted work.
Results
A total of 177 patients met inclusion criteria; 117 were excluded, leaving 40 normal and 20 positive tests. During normal exercise, global MWI increased 54% (from 2,296 to 3,523 mm Hg%) and efficiency remained at 96%. However, in patients with inducible ischemia, MWI decreased in affected segments, global MWI did not increase (2,069-2,070 mm Hg%), and global efficiency fell from 93% to 87%. The receiver operating characteristic curve for MWI had an area under the curve of 0.94.
Conclusions
During normal exercise, MWI increases and efficiency remains unchanged. However, during exercise-induced ischemia, MWI paradoxically decreases in affected segments, while globally MWI fails to increase and efficiency decreases. We have demonstrated that MWI can be applied to stress echocardiography to identify ischemia, but its utility remains uncertain. Further research that makes comparisons with an objective measure of functional ischemia is needed.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1191-1200
Borrie A, Goggin C, Ershad S, Robinson W, Sasse A
J Am Soc Echocardiogr: 29 Sep 2020; 33:1191-1200 | PMID: 32651126
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography.

Johri AM, Nambi V, Naqvi TZ, Feinstein SB, ... Becher H, Sillesen H

Atherosclerotic plaque detection by carotid ultrasound provides cardiovascular disease risk stratification. The advantages and disadvantages of two-dimensional (2D) and three-dimensional (3D) ultrasound methods for carotid arterial plaque quantification are reviewed. Advanced and emerging methods of carotid arterial plaque activity and composition analysis by ultrasound are considered. Recommendations for the standardization of focused 2D and 3D carotid arterial plaque ultrasound image acquisition and measurement for the purpose of cardiovascular disease stratification are formulated. Potential clinical application towards cardiovascular risk stratification of recommended focused carotid arterial plaque quantification approaches are summarized.

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

J Am Soc Echocardiogr: 30 Jul 2020; 33:917-933
Johri AM, Nambi V, Naqvi TZ, Feinstein SB, ... Becher H, Sillesen H
J Am Soc Echocardiogr: 30 Jul 2020; 33:917-933 | PMID: 32600741
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Altered Biatrial Phasic Function after Heart Transplantation in Children.

Parthiban A, Jani V, Zhang J, Li L, ... Danford DA, Kutty S
Purpose
We used two-dimensional echocardiographic speckle-tracking to investigate whether left and right atrial (LA and RA) phasic function in pediatric heart transplantation (HT) patients is altered and explored the relationship to HT-related clinical variables.
Methods
Eighty-six subjects (36 HT and 50 normal children) were prospectively enrolled in two centers. Clinical data included age at HT, bypass time, ischemia time, donor age, and incidence of rejection. Atrial deformation indices including strain and strain rates (SRs) were measured using two-dimensional echocardiographic speckle-tracking. Components of phasic atrial function-reservoir (ε, SR), conduit (ε, SR), and booster (ε, SR) were calculated. Comparisons with controls were made using t test or Kruskal-Wallis test, and correlations to clinical variables were explored.
Results
The mean age and body surface area of HT subjects were 10.2 ± 6.2 years and 1.2 ± 0.6 m, respectively. The mean heart rates were higher in HT (96 ± 18 vs 88 ± 21 in controls). There were reductions in RA and LA reservoir (ε, SR), conduit (ε, SR), and booster (ε, SR) function in HT compared with controls. There was no relationship of LA and RA deformation indices with mean age at HT, bypass time, or ischemia time. The LA ε correlated weakly with donor age (r = -0.49, P = .04) and RA SR, and SR showed association with duration of HT (P < .05). Nineteen HT recipients had follow-up studies 0.24 ± 0.18 years after the first examination, and deformational indices were not significantly changed.
Conclusions
Atrial strain determination is feasible in pediatric HT recipients and demonstrates disruption of reservoir, conduit, and booster function of both atria in this population; we speculate this may be a consequence of ventricular diastolic dysfunction.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1132-1140.e2
Parthiban A, Jani V, Zhang J, Li L, ... Danford DA, Kutty S
J Am Soc Echocardiogr: 30 Aug 2020; 33:1132-1140.e2 | PMID: 32653298
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Myocardial Work in Nonobstructive Hypertrophic Cardiomyopathy: Implications for Outcome.

Hiemstra YL, van der Bijl P, El Mahdiui M, Bax JJ, Delgado V, Marsan NA
Background
Noninvasive left ventricular (LV) pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate LV function, integrating longitudinal strain by speckle-tracking analysis and sphygmomanometrically measured blood pressure to estimate myocardial work. The aims of this study were (1) to describe global and segmental myocardial work in patients with hypertrophic cardiomyopathy (HCM), (2) to assess the correlation between myocardial work and other echocardiographic parameters, and (3) to evaluate the association of myocardial work with adverse outcomes.
Methods
One hundred ten patients with nonobstructive HCM (mean age, 55 ± 15 years; 66% men), with different phenotypes (apical, concentric, and septal hypertrophy), and 35 age- and sex-matched healthy control subjects were included. The following myocardial work indices were included: myocardial work index, constructive work (CW), wasted work, and cardiac efficiency. The combined end point included all-cause mortality, heart transplantation, heart failure hospitalization, aborted sudden cardiac death, and appropriate implantable cardioverter-defibrillator therapy.
Results
Mean global CW (1,722 ± 602 vs 2,274 ± 574 mm Hg%, P < .001), global cardiac efficiency (93% [89%-95%] vs 96% [96%-97%], P < .001), and global MWI (1,534 ± 551 vs 1,929 ± 473 mm Hg%) were significantly reduced, while global wasted work (104 mm Hg% [66-137 mm Hg%] vs 71 mm Hg% [49-92 mm Hg%], P < .001) was increased in patients with HCM compared with control subjects. Segmental impairment in CW colocalized with maximal wall thickness (HCM phenotype), and global CW correlated with LV wall thickness (r = -0.41, P < .001), diastolic function (r = -0.27, P = .001), and QRS duration (r = -0.28, P = .001). Patients with global CW > 1,730 mm Hg% (the median value) experienced better event-free survival than those with global CW < 1,730 mm Hg% (P < .001).
Conclusions
Myocardial work, assessed noninvasively using echocardiography and blood pressure measurement, is reduced in patients with nonobstructive HCM; it correlates with maximum LV wall thickness and is significantly associated with a worse long-term outcome.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1201-1208
Hiemstra YL, van der Bijl P, El Mahdiui M, Bax JJ, Delgado V, Marsan NA
J Am Soc Echocardiogr: 29 Sep 2020; 33:1201-1208 | PMID: 32680744
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease: A Report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography.

, Sachdeva R, Valente AM, Armstrong AK, ... Sachdeva R, Winchester DE

The American College of Cardiology (ACC) collaborated with the American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Pediatric Echocardiography to develop Appropriate Use Criteria (AUC) for multimodality imaging during the follow-up care of patients with congenital heart disease (CHD). This is the first AUC to address cardiac imaging in adult and pediatric patients with established CHD. A number of common patient scenarios (also termed \"indications\") and associated assumptions and definitions were developed using guidelines, clinical trial data, and expert opinion in the field of CHD. The indications relate primarily to evaluation before and after cardiac surgery or catheter-based intervention, and they address routine surveillance as well as evaluation of new-onset signs or symptoms. The writing group developed 324 clinical indications, which they separated into 19 tables according to the type of cardiac lesion. Noninvasive cardiac imaging modalities that could potentially be used for these indications were incorporated into the tables, resulting in a total of 1,035 unique scenarios. These scenarios were presented to a separate, independent panel for rating, with each being scored on a scale of 1 to 9, with 1 to 3 categorized as \"Rarely Appropriate,\" 4 to 6 as \"May Be Appropriate,\" and 7 to 9 as \"Appropriate.\" Forty-four percent of the scenarios were rated as Appropriate, 39% as May Be Appropriate, and 17% as Rarely Appropriate. This AUC document will provide guidance to clinicians in the care of patients with established CHD by identifying the reasonable imaging modality options available for evaluation and surveillance of such patients. It will also serve as an educational and quality improvement tool to identify patterns of care and reduce the number of Rarely Appropriate tests in clinical practice.

Copyright © 2020 The American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Sep 2020; 33:e1-e48
, Sachdeva R, Valente AM, Armstrong AK, ... Sachdeva R, Winchester DE
J Am Soc Echocardiogr: 29 Sep 2020; 33:e1-e48 | PMID: 33010859
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Impact of Anemia on Exercise and Pharmacologic Stress Echocardiography.

Bird JG, Morant K, Al-Souri D, Scott CG, ... Pellikka PA, Luis SA
Background
The safety and diagnostic accuracy of stress testing in anemic patients have not been well studied. Despite a lack of data, significant anemia may be considered a relative contraindication to stress testing because of safety concerns related to insufficient myocardial oxygen supply.
Methods
The authors reviewed 28,829 consecutive patients with blood hemoglobin drawn within 48 hours of stress echocardiography (15,624 exercise and 13,205 dobutamine). The associations of blood hemoglobin concentration with arrhythmia and other stress echocardiographic findings were examined. Additionally, the effect of anemia on the positive predictive value of stress echocardiography for the detection of significant coronary artery stenosis (≥50%) was assessed in patients who subsequently underwent coronary angiography.
Results
Anemia was present in 6,401 patients (22.2%) and was severe (hemoglobin < 8.0 g/dL) in 52. Stress testing with either exercise or dobutamine was safe, with no significant increase in serious arrhythmia events or need for hospitalization. In the exercise cohort, worsening anemia was associated with reduced treadmill exercise time, lower peak heart rate, peak rate-pressure product, and achieved workload. In the dobutamine stress cohort, worsening anemia was associated with higher resting heart rate, more use of atropine, and fewer patients attaining target heart rate. The positive predictive value of stress echocardiography was higher in patients with moderate anemia compared with those without anemia (71.8% vs 60.2%, P = .01).
Conclusions
This study demonstrates that stress testing is safe in patients with mild and moderately anemia, albeit with a small increase in mild supraventricular arrhythmias with exercise. However, worsening anemia was associated with a significant reduction in exercise capacity. Additionally, worsening anemia was associated with an improvement in the positive predictive value of stress echocardiography. Extrapolation of these data to patients with severe anemia should be performed with caution given the limited number of patients with severe anemia in this study.

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

J Am Soc Echocardiogr: 30 Aug 2020; 33:1067-1076
Bird JG, Morant K, Al-Souri D, Scott CG, ... Pellikka PA, Luis SA
J Am Soc Echocardiogr: 30 Aug 2020; 33:1067-1076 | PMID: 32709477
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print
Mele D, Pestelli G, Molin DD, Smarrazzo V, ... Flamigni F, Ferrari R
J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print | PMID: 32741596
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Protective Effects of Statin and Angiotensin Receptor Blocker in a Rat Model of Doxorubicin- and Trastuzumab-Induced Cardiomyopathy.

Cho DH, Lim IR, Kim JH, Kim MN, ... Park SM, Shim WJ
Background
Chemotherapy has led to improved survival in patients with breast cancer; however, it is associated with an increased risk of cardiac dysfunction and heart failure. We investigated the protective effects of rosuvastatin and candesartan, alone and in combination, in a doxorubicin- and trastuzumab-induced rat model of cardiomyopathy.
Methods
Forty-two rats were allocated into six groups (G1-G6): G1, control; G2, doxorubicin only; G3, doxorubicin + trastuzumab; G4, doxorubicin + trastuzumab + rosuvastatin; G5, doxorubicin + trastuzumab + candesartan; and G6, doxorubicin + trastuzumab + rosuvastatin + candesartan. Doxorubicin and trastuzumab were sequentially administered for 28 days. Left ventricular end-systolic dimension and longitudinal strain (LS) were assessed via echocardiography. Left ventricular (LV) performance was evaluated using a microcatheter in the LV apex on day 28. Blood for biomarker analysis was collected from the inferior vena cava before sacrifice.
Results
Doxorubicin in combination with trastuzumab increased the LV end-systolic dimension but worsened LS compared with the control group (all P < .05). The level of C-reactive protein was lower in the rosuvastatin treatment group (P = .007) than in the controls but not in the candesartan treatment group. Both rosuvastatin and candesartan attenuated the increase in glutathione. Candesartan treatment improved +dP/dt (P = .011), whereas rosuvastatin did not. In the combination treatment group, the worsening of LS was significantly attenuated compared with that in either the rosuvastatin or candesartan group (all P < .05).
Conclusions
In a rat model of doxorubicin- and trastuzumab-induced cardiomyopathy, rosuvastatin alleviated systemic inflammation, while candesartan improved LV performance. Combination therapy with rosuvastatin and candesartan demonstrated additional preventive effects on myocardial strain. The protective mechanisms of rosuvastatin and candesartan appear to be different but complementary in chemotherapy-induced cardiomyopathy.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1253-1263
Cho DH, Lim IR, Kim JH, Kim MN, ... Park SM, Shim WJ
J Am Soc Echocardiogr: 29 Sep 2020; 33:1253-1263 | PMID: 32778498
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 02 Sep 2020; epub ahead of print
Amadio JM, Bouck Z, Sivaswamy A, Chu C, ... Weiner RB, Bhatia RS
J Am Soc Echocardiogr: 02 Sep 2020; epub ahead of print | PMID: 32893052
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Fraiche AM, Manning WJ, Nagueh SF, Main ML, Markson LJ, Strom JB
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919859
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Harake D, Gnanappa GK, Alvarez SGV, Whittle A, ... Noga M, Khoo NS
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919855
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Dahl Pedersen AL, Povlsen JA, Dybro A, Clemmensen TS, ... Ladefoged B, Poulsen SH
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919852
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Factors Influencing Temporal Trends in Pediatric Inpatient Imaging Utilization.

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

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

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Anderson S, Figueroa J, McCracken CE, Cochran C, ... Border WL, Sachdeva R
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919851
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Narang A, Hitschrich N, Mor-Avi V, Schreckenberg M, ... Lang RM, Mumm B
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981791
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The 21st Annual Feigenbaum Lecture: Beyond Artificial: Echocardiography from Elegant Images to Analytic Intelligence.

Kutty S

Echocardiography has always been a journey from scientific observation to clinical application. Whether in theranostics, understanding the performance of the systemic right ventricle, or uncovering the predictive power of echocardiographic data in congenital heart disease, the author\'s experiences highlight how echocardiographers at the frontier of scientific inquiry making observations today are inundated with data. It becomes apparent that new clinical applications, if they are to be successful, depend more than ever on effective management of the information we collect. In light of this realization, the 21st Feigenbaum lecture explores analytic intelligence-one path echocardiography might now take on its march from observation to application.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1163-1171
Kutty S
J Am Soc Echocardiogr: 29 Sep 2020; 33:1163-1171 | PMID: 33010852
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Natural Course of Nonsevere Secondary Tricuspid Regurgitation.

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

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

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Spinka G, Bartko PE, Heitzinger G, Prausmüller S, ... Hülsmann M, Goliasch G
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036820
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

J Am Soc Echocardiogr: 14 Oct 2020; epub ahead of print
Lorinsky MK, Belanger MJ, Shen C, Markson LJ, ... Manning WJ, Strom JB
J Am Soc Echocardiogr: 14 Oct 2020; epub ahead of print | PMID: 33071045
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

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

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

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

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

J Am Soc Echocardiogr: 11 Oct 2020; epub ahead of print
Vainrib A, Massera D, Sherrid MV, Swistel DG, ... Williams MR, Saric M
J Am Soc Echocardiogr: 11 Oct 2020; epub ahead of print | PMID: 33059963
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.