Journal: J Am Soc Echocardiogr

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Abstract

23 Annual Feigenbaum Lecture: History of Echocardiography: A Personal Perspective.

Pearlman AS, Feigenbaum H
Ultrasound was first used to examine the cardiovascular system about 70 years ago. The evolution of echocardiography as a family of diagnostic methods has been marked by ongoing development of novel technologies and clinical applications. The history is interesting and may be of particular interest to those practitioners who use echocardiography to enhance the care of their patients but who do not remember the \"early days\" of this field. In this article, based on the 23rd Feigenbaum Lecture, the authors discuss the history of echocardiography from the personal perspective of one of the clinicians who has been a leader in this field for more than 60 years.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 28 Sep 2022; epub ahead of print
Pearlman AS, Feigenbaum H
J Am Soc Echocardiogr: 28 Sep 2022; epub ahead of print | PMID: 36182044
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Abstract

Taking Command of 3D Stitching Artifacts: From an Annoyance to an Easy Tool for Navigating 3D Transesophageal Echocardiography.

Maidman SD, Bamira D, Ro R, Vainrib AF, Saric M
Despite many recent advances in three-dimensional (3D) transesophageal (TEE) imagining, the process of orienting 3D TEE images is nonintuitive and uses assumptions based on idealized anatomy. Correlating two-dimensional (2D) TEE cross-sectional images to 3D reconstructions remains an additional challenge. Here, we suggest the repurposing of the stitching artifact generated in 2-beat ECG-gated 3D TEE as a means of exactly orienting 3D images within a patient\'s unique anatomy. In this article, we demonstrate this application of this strategy to assess a normal mitral valve (MV), to localize scallops of mitral valve prolapse and to visualize typical left atrial appendage 2D cuts in a 3D space. By taking command of stitching artifacts, cardiac imagers can successfully navigate the complex structures of the heart for optimal, individualized echocardiographic views.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Sep 2022; epub ahead of print
Maidman SD, Bamira D, Ro R, Vainrib AF, Saric M
J Am Soc Echocardiogr: 26 Sep 2022; epub ahead of print | PMID: 36174809
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Abstract

Atrial Cardiomyopathy with Impaired Functional Reserve in Patients with Paroxysmal Atrial Fibrillation.

Cho DH, Kim YG, Choi J, Kim HD, ... Shim WJ, Park SM
Background
Impaired atrial functional reserve during exercise may represent an early stage of atrial cardiomyopathy. To test this hypothesis, we evaluated left atrial (LA) and left ventricular (LV) function reserve during exercise in patients with paroxysmal atrial fibrillation (PAF).
Methods
Sixty-one patients with PAF undergoing radiofrequency catheter ablation and 38 healthy controls were prospectively enrolled. LV global longitudinal strain (GLS) and LA reservoir strain (LA-RS) were measured at rest and during supine bicycle exercise. To identify the early stage of atrial cardiomyopathy without LA structural remodeling, patients with PAF were divided into two groups according to LA volume index (LAVI): AF group 1 (LAVI ≥34 mL/m2) and AF group 2 (LAVI <34 mL/m2).
Results
LV ejection fraction and GLS did not differ between patients with AF and controls. LAVI and LA-RS did not differ between AF group 2 and the controls. During exercise, LV-GLS improved in all groups. Increases in LA-RS were attenuated in both AF groups, which also exhibited lower LA functional reserve index (LAFRI) than the controls. Although resting LA-RS was similar between AF group 2 and the controls, LAFRI was significantly lower in AF group 2. LAFRI was associated with the risk of AF recurrence (hazard ratio: 0.852; 95% confidence interval: 0.736-0.988).
Conclusions
Atrial cardiomyopathy could be anticipated by impaired LA functional reserve during exercise in patients with AF, even in those with normal-sized LA. Atrial cardiomyopathy occurs independently of changes in LV function, and is associated with the recurrence of AF in patients with PAF after radiofrequency catheter ablation.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Sep 2022; epub ahead of print
Cho DH, Kim YG, Choi J, Kim HD, ... Shim WJ, Park SM
J Am Soc Echocardiogr: 23 Sep 2022; epub ahead of print | PMID: 36162771
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Abstract

Low Pulmonary Artery Pulsatility Index by Echocardiography is Associated with Increased Mortality in Pulmonary Hypertension.

Kane CJ, Salama AA, Pislaru C, Kane GC, Pislaru SV, Lin G
Background
Pulmonary hypertension (PH) is a progressive pulmonary vascular disorder with elevated mortality risk. Pulmonary artery (PA) pulsatility index (PAPi) based on invasively acquired parameters has emerged as a hemodynamic risk predictor. Whether noninvasively derived PAPi (PA pulse pressure divided by right atrial (RA) pressure) is valuable is unclear.
Methods
Consecutive patients undergoing transthoracic echocardiography for known or suspected PH were included with conventional echocardiographic measures of PA systolic, PA diastolic, and estimated RA pressures. In those patients with PH (mean PA pressure > 20 mm Hg), PAPi was divided into 3 groups; <1.5, 1.5 to 3, and >3. Mortality was assessed over 5 years.
Results
Of 1,045 patients enrolled, 64% had PH. Patients with the lowest PAPi had higher NT-proBNP levels, larger right ventricles (RV), worse right heart systolic function and greater degrees of tricuspid regurgitation. In patients with PH, PAPi was inversely proportional to the risk of death, with PAPi <3 associated with a 1.96-fold increased risk of death (95% CI 1.45-2.64, p<.0001). At multivariate analysis, RV longitudinal systolic strain (HR 1.45, 1.24-1.71; p<.0001), PAPi <3 (HR 1.76, 1.31-2.37; p=.0002), and the presence of a pericardial effusion (HR 1.64, 1.20-2.26 p=.003) were independently associated with increased mortality. In age- and sex-adjusted model, PAPi was incremental to PA compliance.
Conclusions
In patients with PH, low PAPi, derived noninvasively by transthoracic echocardiography, is associated with markers of right heart failure, RV dysfunction and worse survival. PAPi could be incorporated into the conventional echo parameters reported in patients with PH and may be a useful predictor of outcome.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 17 Sep 2022; epub ahead of print
Kane CJ, Salama AA, Pislaru C, Kane GC, Pislaru SV, Lin G
J Am Soc Echocardiogr: 17 Sep 2022; epub ahead of print | PMID: 36126823
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Abstract

Clinical, experimental, and computational validation of a new Doppler-based index for coarctation severity assessment.

Ghorbannia A, Ellepola CD, Woods RK, Ibrahim EH, ... Ramirez HM, LaDisa JF
Background
Long-term morbidity including hypertension often persists in coarctation patients despite current guidelines. Coarctation severity can be invasively assessed via peak-to-peak catheter pressure gradient (PPCG), which is estimated noninvasively via simplified Bernoulli equation and conventionally reported as peak instantaneous Doppler gradient (PIDG). However, underlying simplifications of the equation limit diagnostic accuracy. We studied the diagnostic performance of a new Doppler-based diastolic index called the continuous flow pressure gradient (CFPG) versus conventional indices in assessing coarctation severity.
Methods
In a rabbit model mimicking human aortic coarctation, temporal blood pressure waveforms revealed diastolic instantaneous pressure gradients and spectral Doppler features impacted by coarctation severity. We therefore hypothesized CFPG provides superior correlation with coarctation gradients measured invasively. PIDG and CFPG were quantified using color flow echocardiography in humans and rabbits with discrete coarctations. Results were compared with PPCG in rabbits (n=34) and arm-leg systolic pressure gradients (ALSG; n=25) in humans via one-way ANOVA, Pearson\'s correlation, linear regression, and Bland-Altman analysis.
Results
A threshold of CFPG ≥4.6 mmHg was identified via Youden index as representative of PPCG ≥20 mmHg (the current guideline value for coarctation intervention) in rabbits, while a CFPG ≥1.0 mmHg represented an ALSG ≥20 mmHg in humans. Accuracy measures revealed superior correlation of CFPG (R2 >0.80) and mild ROC improvement (AUC 0.94-0.95) as compared to PIDG (R2 <0.63, AUC 0.89-0.95). Inter/intra-observer variability tested by intraclass correlation coefficient revealed measurement reliability with differences ≤8.2 and 10.7%, respectively. Computational simulations of anaesthetized versus conscious hemodynamics showed parameters were minimally impacted by isoflurane inherent in data used to derive CFPG. These results confirm the potential diagnostic accuracy of CFPG in echocardiography-based coarctation severity assessment. We are optimistic that CFPG will be useful for translation of results from pre-clinical studies that revisit current guidelines in order to limit morbidity in humans with aortic coarctation.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 16 Sep 2022; epub ahead of print
Ghorbannia A, Ellepola CD, Woods RK, Ibrahim EH, ... Ramirez HM, LaDisa JF
J Am Soc Echocardiogr: 16 Sep 2022; epub ahead of print | PMID: 36122791
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Abstract

INCREASED SUSCEPTIBILITY FOR ADVERSE REACTIONS TO ULTRASOUND ENHANCING AGENTS IN SICKLE CELL DISEASE.

Wu M, Fields JJ, Sachdev V, Belcik RT, ... Swistara G, Lindner JR
Background
Pain-related adverse events (AEs) to ultrasound enhancing agents (UEAs) have been reported in patients with sickle cell disease (SCD). Our aim was to characterize the scope of these AEs in the SCD population and to investigate potential mechanisms based on pathways involved in SCD vaso-occlusive crisis (VOC) and pain.
Methods
The prevalence and classification of AEs were analyzed from two clinical trials where high-dose Definity infusions were used in patients with SCD (n=55) or matched controls (n=43) to study muscle or myocardial microvascular perfusion. Because complement (C\') activation can trigger VOC in SCD, C\' activation and surface adhesion of C\' proteins on lipid UEAs were studied in vitro. C\'-mediated UEA attachment to bone marrow immune cells was assessed by flow cytometry in a murine SCD model (Townes mice). Blood from patients receiving Definity was obtained to measure specific lysophospholipid metabolites of lipids in Definity thought to mediate SCD pain.
Results
Moderate or greater AEs, all of which were nociceptive (back or bone pain), occurred in one control subject and nine SCD subjects (2% vs. 16%, p=0.02). SCD patients with AEs tended to have more severe manifestations of SCD. Three of the SCD subjects previously received Definity without complication. In SCD patients, four AEs were classified as severe in intensity, and as serious AEs based on need for medical intervention. AEs were described to be similar to SCD-related pain, but there was no evidence for VOC, hemolysis, hypotension, or hypoxemia. At baseline, markers of C\' activation were greater in SCD patients than controls at baseline. However, after lipid UEAs, SCD and control subjects were similar with regard to C\' activation response, anaphylatoxin production, bone marrow microbubble retention, and production of lysophospholipids. There was a trend for increased deposition of C3b and C3bi on lipid UEAs for SCD patients.
Conclusion
Patients with SCD are particularly susceptible to nociceptive AEs when given Definity at high doses. The mechanism for these AEs remains unclear, but is not related to the triggering of classic VOC.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 13 Sep 2022; epub ahead of print
Wu M, Fields JJ, Sachdev V, Belcik RT, ... Swistara G, Lindner JR
J Am Soc Echocardiogr: 13 Sep 2022; epub ahead of print | PMID: 36113741
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Abstract

The association of aortic valve sclerosis, aortic annulus increased reflectivity, and mitral annular calcification with subsequent aortic stenosis in older individuals. Findings from the Cardiovascular Health Study.

Barasch E, Gottdiener JS, Tressel W, Bartz TM, ... Kizer JR, Owens D
Background
While aortic valve sclerosis (AVS) is well-described as preceding aortic stenosis (AS), the association of AS with antecedent mitral aortic annular calcification and aortic annulus increased reflectivity (MAC and AAIR, respectively) has not been characterized. In a population-based prospective study, we evaluated whether MAC, AAIR, and AVS are associated with the risk of incident AS.
Methods
Among participants of the Cardiovascular Health Study (CHS) free of AS at the 1994-1995 visit, the presence of MAC, AAIR, AVS, and the combination of all three were evaluated in 3041 participants. Cox proportional hazards regression was used to assess the association between the presence of calcification and the incidence of moderate/severe AS in three nested models adjusting for factors associated with atherosclerosis and inflammation both relevant to the pathogenesis of AS.
Results
Over a median follow-up of 11.5 years (IQR 6.7 to 17.0), 110 cases of incident moderate/severe AS were ascertained. Strong positive associations with incident moderate/severe AS were found for all calcification sites after adjustment for the main model covariates: AAIR (HR=2.90, 95% CI=[1.95, 4.32], p<0.0005), AVS (HR=2.20, 95% CI=[1.44, 3.37], p<0.0005), MAC (HR=1.67, 95% CI=[1.14, 2.45], p=0.008), and the combination of MAC, AAIR, and AVS (HR=2.50, 95% CI=[1.65, 3.78], p<0.0005). In a secondary analysis, the risk of AS increased with the number of sites at which calcification was present.
Conclusions
In a large cohort of community-dwelling elderly individuals, there were strong associations between each of AAIR, AVS, MAC, and the combination of MAC, AAIR, and AVS with incident moderate/severe AS. The novel finding that AAIR had a particularly strong association with incident AS, even after adjusting for other calcification sites, suggests its value in identifying individuals at risk for AS, and potential inclusion in the routine assessment by transthoracic echocardiography.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 09 Sep 2022; epub ahead of print
Barasch E, Gottdiener JS, Tressel W, Bartz TM, ... Kizer JR, Owens D
J Am Soc Echocardiogr: 09 Sep 2022; epub ahead of print | PMID: 36096340
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Abstract

Echocardiography Provides a Reliable Estimate of Total Cardiac Volume for Pediatric Heart Transplantation.

Szugye NA, Shuler JM, Pradhan S, Plasencia JD, ... Morales DLS, Moore RA
Background
Donor to recipient size matching for heart transplantation typically involves comparing donor and recipient body weight, however weight is not linearly related to cardiac size. Attention has shifted toward use of computed tomography (CT) derived Total Cardiac Volume (TCV), i.e., CT-TCV, to compare donor and recipient heart organ size. At this time, TCV size matching is near-impossible for most centers due to logistical limitations. To overcome this impediment, echocardiography-derived TCV (ECHO-TCV) is an attractive, alternative option to estimate CT-TCV. The goal of this work is to test whether ECHO-TCV is an accurate and reliable surrogate for TCV measurement compared with the gold standard CT-TCV.
Methods
ECHO-TCV and CT-TCV were measured in a cohort spanning the neonatal to young adult age range intended to simulate the pediatric heart transplant donor pool. ECHO-TCV was measured using a modified Simpson\'s summation of discs method from the apical 4 chamber (A4C) view. The gold standard of CT-TCV was measured from CT scans using 3D reconstruction software. The relationship between ECHO-TCV and CT-TCV was evaluated and compared with other anthropometric and image-based markers that may predict CT-TCV. Inter-rater reliability of ECHO-TCV was tested among 4 independent observers. Sub-analyses were performed to identify imaging views and timing that enable greater accuracy of ECHO-TCV.
Results
Banked imaging data of 136 subjects with both echocardiogram and CT were identified. ECHO-TCV demonstrated a linear relationship to CT-TCV with Pearson correlation coefficient of r=0.96 (95% CI 0.95 - 0.97, p<0.0001) and mean absolute percent error (MAPE) of 8.6%. ECHO-TCV correlated most strongly with CT-TCV in the subset of subjects <4 years of age (n=33, r= 0.98, 95% CI 0.96-0.99, p<0.0001). The single-score intraclass correlation coefficient across all 4 raters is 0.96 (IQR 0.93 - 0.98). ECHO-TCV measured from a standard A4C view at end-diastole with the atria in the plane-of-view had the strongest correlation to CT-TCV.
Conclusion
ECHO-TCV by A4C view was found to be both an accurate and reliable alternative measurement of CT-TCV and is derived from readily available donor ECHO images. The ECHO-TCV findings in this study make the ECHO method an attractive means of direct donor to recipient TCV size matching in pediatric heart transplantation.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 07 Sep 2022; epub ahead of print
Szugye NA, Shuler JM, Pradhan S, Plasencia JD, ... Morales DLS, Moore RA
J Am Soc Echocardiogr: 07 Sep 2022; epub ahead of print | PMID: 36087887
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Abstract

A Novel Handheld Echocardiography Device with Continuous-Wave Doppler Capability: Implications for the Evaluation of Aortic Stenosis Severity.

Sachpekidis V, Papadopoulou SL, Kantartzi V, Styliadis I, Nihoyannopoulos P
Background
The aim of this study was to evaluate the ability of a novel handheld echocardiography (HHE) device with continuous-wave Doppler (CWD) capability to measure peak aortic valve jet velocity (Vmax) and facilitate aortic stenosis (AS) severity grading.
Methods
We prospectively included 121 consecutive patients with known or suspected AS. All patients were scanned with the HHE and the high-end echocardiography system (reference standard) in order to obtain CWD signal across the aortic valve. The aortic Vmax measurements were acquired from the apical 5-chamber view by both methods and were compared to assess method agreement using intra-class correlation coefficient (ICC), linear regression analysis and Bland-Altman analysis. The diagnostic accuracy for the detection of at least moderate AS (Vmax≥3 m/s) was calculated. Also, the utility of HHE with CWD to reclassify patients compared to the visual estimation of AS severity was assessed.
Results
The acquisition of CWD signal using HHE was feasible in 118 out of 121 patients (mean age 68±17years old, 57% male). There was excellent agreement between the HHE CWD and the cart-based measurements (ICC=0.97; 95%CI 0.83-0.99 and r=0.98; 95%CI 0.91-0.99, p<0.001 for both). The Bland-Altman plot showed a small underestimation bias of -0.2 m/s (p<0.001), with limits of agreement ±0.44 m/s for the Vmax. Detection of at least moderate AS using the HHE with CWD was feasible with sensitivity 93% (95%CI 83%-98%), specificity 98% (95%CI 91%-100%), PPV 98% (95%CI 88%-100%), NPV 94% (95%CI 85%-97%) and a total diagnostic accuracy of 96%.The patients visually assessed as mild AS cases were reclassified as no stenosis (17%), mild (72%) and moderate (11%) AS with the addition of CWD imaging.
Conclusion
Use of a novel HHE device with CWD spectral analysis by experienced operators can reliably detect clinically significant AS and facilitate AS grading. This technology may improve screening and diagnostic workup of AS compared to current practice.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 01 Sep 2022; epub ahead of print
Sachpekidis V, Papadopoulou SL, Kantartzi V, Styliadis I, Nihoyannopoulos P
J Am Soc Echocardiogr: 01 Sep 2022; epub ahead of print | PMID: 36058491
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Abstract

Significance of Spontaneous Echocardiographic Contrast in Transcatheter Edge-to-edge Repair for Mitral Regurgitation.

Sato H, Cavalcante J, Enriquez-Sarano M, Bae R, ... Bapat VN, Sorajja P
Background
Spontaneous echocardiographic contrast (SEC) in the left atrium can occur with transcatheter edge-to-edge repair (TEER), yet the clinical significance is unknown.
Methods
We examined the clinical association of the procedural appearance of SEC in 316 patients (age 82 [76, 86] years; 43.4% women) undergoing TEER with MitraClip for mitral regurgitation (MR). Acute, 30-day, and 2-year clinical outcomes were analyzed.
Results
SEC was common, occurring following device implantation in 106 patients (34%). While occurrence of SEC was not related to clinical characteristics, such as atrial fibrillation, anticoagulant use, or left ventricular function, there was a strong relation to beneficial outcomes with TEER. The frequency of optimal reduction in mitral regurgitation was higher in patients who had SEC (99.1% vs 72.9%.; p<0.001). Survival was greater, with the two-year estimate for freedom from all-cause mortality of 88.4% vs. 71.5 (log-rank p=0.004). Importantly, the higher survival observed in SEC patients was present without increased rates of procedural complications or stroke, and remained significant in multivariate analyses that adjusted for baseline clinical and echocardiographic variables (p=0.01).
Conclusions
The occurrence of SEC in patients with TEER is associated with beneficial acute and intermediate-term outcomes.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 29 Aug 2022; epub ahead of print
Sato H, Cavalcante J, Enriquez-Sarano M, Bae R, ... Bapat VN, Sorajja P
J Am Soc Echocardiogr: 29 Aug 2022; epub ahead of print | PMID: 36049594
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Abstract

An Automated View Classification Model for Pediatric Echocardiography Using Artificial Intelligence.

Gearhart A, Goto S, Deo RC, Powell AJ
Background
View classification is a key step toward building a fully automated system for echocardiogram interpretation. However, compared to adult echocardiograms, creating a view classification model for pediatric echocardiograms poses additional challenges such as greater variation in anatomy, structure size, and views.
Objectives
We sought to develop a computer vision model to autonomously perform view classification on pediatric echocardiographic images.
Methods
Using a training set of 12,067 echocardiogram images from patients age 0 to 19 years, a convolutional neural network (CNN) model was trained to identify 27 pre-selected standard pediatric echocardiogram views that included anatomic sweeps, color Doppler, and Doppler tracings. A validation set of 6,197 images was used for parameter tuning and model selection. A test set of 9,684 images from 100 different patients was then used to evaluate model accuracy. The model was also evaluated on a per study basis using a second test set consisting of 524 echocardiograms from children with leukemia to identify 6 pre-selected views pertinent to cardiac dysfunction surveillance.
Results
The model identified the 27 pre-selected views with 90.3% accuracy. Accuracy was similar across age groups (89.3% for 0-4 yr, 90.8% for 4-9 yr, 90.0% for 9-14 yr, and 91.2% for 14-19 yr, P=0.12). Examining the view subtypes, accuracy was 78.3% for the cine one location, 90.5% for the sweeps with color Doppler, 82.2% for sweeps without color Doppler, and 91.1% for Doppler tracings. Among the leukemia cohort, the model identified the 6 pre-selected views on a per study basis with a positive predictive value of 98.7-99.2% and sensitivity of 76.9-94.8%.
Conclusions
We constructed a CNN model for view classification of pediatric echocardiograms that was accurate across the spectrum of ages and view types. This work lays the foundation for automated quantitative analysis and diagnostic support to promote efficient, accurate, and scalable analysis of pediatric echocardiograms.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 29 Aug 2022; epub ahead of print
Gearhart A, Goto S, Deo RC, Powell AJ
J Am Soc Echocardiogr: 29 Aug 2022; epub ahead of print | PMID: 36049595
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Abstract

Effects of atrial ischemia on left atrial remodeling in patients with ST-segment elevation myocardial infarction.

Montero-Cabezas JM, Abou R, Chimed S, Fortuni F, ... Bax JJ, Delgado V
Aims
Adverse left atrial (LA) remodeling after ST-segment elevation myocardial infarction (STEMI) has been associated with poor prognosis. Flow impairment in the dominant coronary atrial branch (CAB) may affect large areas of LA myocardium, potentially leading to adverse LA remodeling during follow-up. We assessed echocardiographic LA remodeling in STEMI patients with impaired coronary flow in the dominant CAB
Methods:
Of 897 STEMI patients, 69 patients (62±11 years,83% males) with impaired coronary flow in the dominant CAB (defined as TIMI flow<3) were retrospectively compared to an age- and sex-matched control group of 138 patients with normal dominant CAB coronary flow.
Results
Patients with dominant CAB-impaired flow had higher peak troponin T (3.9 μg/L[2.2-8.2] vs.3.2 μg/L[1.5-5.6];p=0.009). No differences in left ventricular ejection fraction or mitral regurgitation were observed between groups neither at baseline nor at follow-up. LA remodeling assessment included maximum LA volume, speckle tracking echocardiography-derived LA strain and total atrial conduction time assessed by tissue Doppler imaging (PA-TDI) at baseline, 6 and 12 months. Patients with dominant CAB-impaired flow presented larger LA maximal volumes (26.9±10.9 vs.18.1±7.1 ml/m2,p<0.001) and longer PA-TDI (150±23 vs.124±22 msec., p<0.001) at 6-months, remaining unchanged at 12-months.However, all LA strain parameters were significantly lower from baseline (reservoir 20.3±10.1% vs.27.1±14.5%,p<0.001;conduit 9.1±5.6% vs.12.8±8%,p<0.001; booster 9.1±5.6% vs.12.8±8%, p<0.001), these differences being sustained at 6- and 12-months follow-up.
Conclusion
Atrial ischemia resulting from an impaired coronary flow in the dominant CAB in patients with STEMI is associated with LA adverse anatomical and functional remodeling. Reduced LA strain preceded LA anatomical remodeling in early phases after STEMI.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 14 Aug 2022; epub ahead of print
Montero-Cabezas JM, Abou R, Chimed S, Fortuni F, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 14 Aug 2022; epub ahead of print | PMID: 35977632
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Abstract

Minute Stroke Distance is a More Reproducible Measurement Than Cardiac Output in the Assessment of Fetal Ventricular Systolic Function.

Sun HY, Selamet Tierney ES, Tacy TA, Punn R
Background
Echocardiographic quantification of fetal cardiac output (CO) aids clinical decision-making in the management of various cardiac and extracardiac diseases. Small variability in measuring semilunar valve dimension significantly reduces the reproducibility of the calculated CO. We propose minute stroke distance or velocity-time integral (VTI) as a more reproducible measure reflecting fetal ventricular systolic function. We hypothesized that right and left ventricular minute VTI increase predictably with estimated fetal weight (EFW) and are more reproducible than CO.
Methods
571 singleton fetuses without cardiovascular pathology between 16-36 weeks gestation were reviewed retrospectively. 22 fetuses with pathology resulting in low or high cardiac output states were also assessed for comparison. VTI was measured in both ventricular outflow tracts at the level of the semilunar valve, excluding a Doppler insonation angle >30°. Heart rate, semilunar valve dimension, and VTI determined minute VTI and CO. Inter-/intra-rater variability were evaluated in a random 10% subset.
Results
Minute VTI and CO measurements were feasible in 67-89% of fetuses in this retrospective study. Minute VTI and CO increased with EFW non-linearly (R=0.61 - 0.94). The mean inter-/intra-rater variability for VTI, 6% and 5.7%, were significantly less than for CO, 25% and 23.7% (p<0.001 for all).
Conclusions
Minute VTI is an easily measured, highly reproducible method of quantifying fetal ventricular systolic function. Variability in calculated CO from valve measurement differences is minimized by solely using VTI. Nomograms of minute VTI provide an efficient and precise assessment of fetal systolic function, and may be utilized to track fetuses in disease states with low or high cardiac output.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 13 Aug 2022; epub ahead of print
Sun HY, Selamet Tierney ES, Tacy TA, Punn R
J Am Soc Echocardiogr: 13 Aug 2022; epub ahead of print | PMID: 35973561
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Abstract

Tricuspid Regurgitation Related to Cardiac Implantable Electronic Devices: An Integrative Review.

Gelves-Meza J, Lang RM, Valderrama-Achury MD, Zamorano JL, ... Medina HM, Salazar G
The use of cardiac implantable electronic devices, including permanent pacemakers, implantable cardiac defibrillators and cardiac resynchronization therapy, has dramatically increased in recent years. The interaction between the device lead and tricuspid valve leaflets is a potential cause of tricuspid regurgitation which in turn has an impact on morbidity and mortality. Echocardiography is necessary for grading of tricuspid regurgitation severity. The use of three-dimensional imaging helps determine whether the device lead is interfering with normal leaflet coaptation. Early identification of lead-related tricuspid regurgitation is critical to select the optimal treatment, which may include lead extraction or even tricuspid valve repair/replacement in severe cases. This review aims to provide a thorough assessment of the evidence about lead-associated tricuspid regurgitation, the benefits of using 3D echocardiography with some technical considerations, and finally, propose a treatment algorithm.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 11 Aug 2022; epub ahead of print
Gelves-Meza J, Lang RM, Valderrama-Achury MD, Zamorano JL, ... Medina HM, Salazar G
J Am Soc Echocardiogr: 11 Aug 2022; epub ahead of print | PMID: 35964911
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Abstract

Echocardiographic measurements of the left heart chambers size in a large cohort of subjects: comparison of body surface area and height indexation to account for effects of obesity.

J M, E G, M C, F G, A P, D C
Background
The assessment of cardiac chamber size in the obese population is a challenging subject. Values usually indexed to body surface area (BSA) are smaller in obese subjects and prone to overcorrection. This study aimed to find reference thresholds to account for effects of obesity from a large cohort of patients and to evaluate the indexation by height as an alternative to BSA.
Methods
The last 10-years records of our Echocardiography Unit were retrospectively analyzed and 14,007 subjects without known cardiac disease were included (45±15 years, 54% women, 20% obese). Measurements included left atrial diameter, area and volume (LAD, LAA and LAV), left ventricular (LV) end-diastolic (LVEDD) and end-systolic diameters (LVESD), aortic root diameter (ARD) and LV mass (LVM). Absolute, BSA and height indexed maximum thresholds (mean+1.96.SD) were calculated. An allometric indexation of the form variable/Heightβ was tested. Correlation coefficients between indexed and absolute values were calculated to evaluate their proportional association (ideally r=1). Correlations between indexed values and body size represented residual associations to be minimized (ideally r=0).
Results
The strongest association of echocardiographic measurements with body size was observed for BSA (r=0.36-0.63), whereas the isometric and allometric height models showed lower comparable values (r=0.28-0.48). Positive correlations with BMI were mostly observed for LA size (r≈0.36) and LVM (r≈0.36) measurements. Scaling exponents β for the allometric height indexation were 1.72 for LAV and 2.33 for LVM. Correlations between indexed and absolute values were higher for height than BSA (0.80-0.98 vs 0.44-0.92). Correlations between indexed values and height were closer to zero than for BSA, particularly using the allometric model. The overcorrection observed with increasing obesity class after BSA indexation was avoided after height indexation.
Conclusions
Unlike BSA, height indexing provided an adequate body size scaling of left heart chambers size avoiding overcorrection using allometric models in particular.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 08 Aug 2022; epub ahead of print
J M, E G, M C, F G, A P, D C
J Am Soc Echocardiogr: 08 Aug 2022; epub ahead of print | PMID: 35953008
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Abstract

Comparison of pre- and postnatally diagnosed coronary artery fistulae: Echocardiographic features and clinical outcomes.

Pisesky A, Nield LE, Rosenthal J, Jaeggi ET, Hornberger LK
Background
Coronary artery fistulae (CAF) are abnormal connections of a coronary artery to a cardiac chamber or vessel. There is a paucity of data regarding clinical outcomes, especially when detected prenatally.
Methods
This was a multi-center retrospective cohort study of all CAF cases from 2002-2016. Clinical characteristics and outcomes were compared between the prenatal and postnatal cohorts. A scoping literature review of prenatal CAFs was completed.
Results
CAFs were diagnosed prenatally in 12 (median 23 (17-36) weeks gestation) and postnatally in 94 (median 2.8 (0-15) years) cases. Structural heart defects were present in 5(42%) prenatal and 19(20%) postnatal cases (p=0.011) and genetic conditions in 5(42%) and 14(15%), respectively (p=0.001). CAFs were considered large in 12(100%) prenatal versus 14(15%) postnatal cases (p<0.001). The CAF distribution was similar between cohorts: 39(67%) from the left and 19(33%) from the right coronary artery with most common exit sites the main pulmonary artery 54(51%), right ventricle 30(28%) and right atrium 12(11%). Of prenatal cases, all large at presentation, none progressed, 6(50%) resolved by birth, and 1(8%) underwent elective neonatal ligation. Of postnatal cases, one presented in cardiogenic shock and no other case had ventricular dysfunction, arrhythmias or ischemic changes. Nine(10%) with large shunts underwent intervention (7 percutaneous, 2 surgical), of whom 3 were symptomatic. Two(17%) prenatal and two(2%) postnatal cases had coronary abnormalities, two with normal stress perfusion. Postnatal death occurred in two(17%) prenatal and four(4%) postnatal cases (p=0.05). Of the total 36 prenatal cases reported in the literature, including the 12 cases in the current series, ten(28%) had clinical symptoms at birth, including three(8%) with cardiogenic shock, and 19(53%) had an intervention.
Conclusion
Prenatally and postnatally encountered CAFs are associated with a good prognosis for most with many not requiring intervention. Although half of the prenatal CAFs resolved prenatally, given the risk of cardiogenic shock at birth and heart failure in early infancy, appropriate perinatal planning and postnatal surveillance is warranted.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Aug 2022; epub ahead of print
Pisesky A, Nield LE, Rosenthal J, Jaeggi ET, Hornberger LK
J Am Soc Echocardiogr: 05 Aug 2022; epub ahead of print | PMID: 35940444
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Abstract

Focused cardiac ultrasound to guide the diagnosis of heart failure in pregnant women in India.

Alsharqi M, Ismavel VA, Arnold L, Choudhury SS, ... Nair M, MaatHRI collaboration
Background
Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low-resource settings. The aim of our study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings.
Methods
Cross-sectional study of 301 pregnant and postpartum women recruited from ten hospitals across three States in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from the Focus-Assessed Transthoracic Echocardiography. It included parasternal long axis (PLAX), parasternal short axis (PSAX), and apical four-chamber views in 2D and colour Doppler. Independent image interpretation was performed remotely by two experts, in the UK and India, using a standard semi-quantitative assessment protocol. Interrater agreement between the experts was examined using Cohen\'s Kappa (κ). Diagnostic accuracy of the method was examined in a sub-sample for whom both focused and conventional scans were available.
Results
Cardiac abnormalities identified using the focused method included valvular abnormalities(27%), rheumatic heart disease(6.6%), derangements in left ventricular size(4.7%) and function(22%), atrial dilatation(19.5%) and pericardial effusion(30%). There was substantial agreement on the cardiac parameters between the two experts ranging from 93.6% (k=0.84) for left ventricular ejection fraction to 100% (k=1) for valvular disease. Image quality was graded as good in 79% of PLAX, 77% PSAX and 64% apical four-chamber views. The chance corrected k coefficients indicated fair to moderate agreement (k 0.28 to 0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement) compared in 36 participants.
Conclusion
The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 04 Aug 2022; epub ahead of print
Alsharqi M, Ismavel VA, Arnold L, Choudhury SS, ... Nair M, MaatHRI collaboration
J Am Soc Echocardiogr: 04 Aug 2022; epub ahead of print | PMID: 35934263
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Abstract

Serial Assessment of Cardiac Function and Pulmonary Hemodynamics in Infants with Down Syndrome.

Smith A, Bussmann N, Breatnach C, Levy P, ... Franklin Mrcpch O, El-Khuffash A
Background
There is a dearth of longitudinal data describing the evolution of cardiopulmonary haemodynamics in infants with Down Syndrome (DS) beyond infancy. We hypothesized that babies with DS, independent of the presence of congenital heart disease (CHD), demonstrate biventricular systolic and diastolic impairment and sustained elevation of pulmonary pressures compared to controls over the first two years of age.
Methods
This was a prospective observational cohort study of 70 infants with DS (48 with CHD and 22 without CHD) and 60 controls carried out in three tertiary neonatal intensive care units in Dublin, Ireland. Infants with DS with and without CHD and non-DS controls underwent serial echocardiograms at birth, 6 months, 1 year and 2 years of age to assess biventricular systolic and diastolic function using deformation analysis. Pulmonary vascular resistance (PVR) was assessed using pulmonary artery acceleration time (PAAT) and left ventricular (LV) eccentricity index.
Results
Infants with DS exhibited smaller LV (Birth: 27±4 vs. 31±2 mm, p<0.01; 2 years: 43±5 vs. 48±4 mm, p<0.01) and RV (Birth: 28±3 vs. 31±2 mm, p<0.01; 2 years: 40±4 vs. 44±3 mm, p<0.01) lengths and lower LV (Birth: -19±3 vs. -22±2 %, p<0.01; 2 years: -24±2 vs. -26±2 %, p<0.01) and RV (Birth: -19±4 vs. -22±3 %, p<0.01; 2 years: -29±6 vs. -33±4 %, p<0.01) systolic strain over the two year period. PAAT was lower in the DS group throughout the study period (Birth: 44±10 vs. 62±14 ms, p<0.01; 2 years 71±12 vs. 83±11 ms, p<0.01). No differences were observed between DS infants with and without CHD (all p >0.05).
Conclusions
Infants with DS exhibit impaired maturational changes in myocardial function and PVR. Such novel findings provide valuable insights into the pathophysiology affecting cardiorespiratory morbidity in this population.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 19 Jul 2022; epub ahead of print
Smith A, Bussmann N, Breatnach C, Levy P, ... Franklin Mrcpch O, El-Khuffash A
J Am Soc Echocardiogr: 19 Jul 2022; epub ahead of print | PMID: 35868547
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Abstract

Human vs Artificial Intelligence-Based Echocardiography Analysis as Predictor of Outcomes: An analysis from the World Alliance Societies of Echocardiography COVID study.

Asch FM, Descamps T, Sarwar R, Karagodin I, ... Lang RM, WASE-COVID Investigators
Background
Transthoracic echocardiography (TTE) is the leading cardiac imaging modality for patients admitted with COVID-19 infection, a condition of high short-term mortality. We aimed to test the hypothesis that artificial intelligence (AI) based analysis of echocardiographic images could predict mortality more accurately than conventional analysis by a human expert.
Methods
Patients admitted to 13 hospitals for acute COVID-19 disease who had a TTE were included. Left ventricular (LV) ejection fraction (EF) and LV longitudinal strain (LS) were obtained manually by multiple expert readers and by an automated, AI software. The ability of the manual and AI analyses to predict all-cause mortality was compared.
Results
870 patients were enrolled, mortality was 27.4% at a follow-up of 230±115 days. AI analysis had lower variability than manual for both LV EF (p=0.003) and LS (p=0.005). AI-derived LV EF and LS were predictors of mortality in univariable and multivariable regression analysis (OR=0.974, 95% CI= 0.956-0.991, p=0.003 for EF; OR=1.060, 95% CI 1.019-1.105, p=0.004 for LS), but LV EF and LS obtained by manual analysis were not. Direct comparison of predictive value of AI vs manual measurements of LV EF and LS was significantly better for AI (p=0.005 and 0.003 respectively). In addition, AI-derived LV EF and LS had more significant and stronger correlations to other objective biomarkers for acute disease than manual reads.
Conclusions
AI-based analysis of LVEF and LVLS had a similar feasibility to manual analysis, minimized variability and consequently increased the statistical power to predict mortality. AI-based analyses, but not manual, were significant predictors of in-hospital and follow-up mortality.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print
Asch FM, Descamps T, Sarwar R, Karagodin I, ... Lang RM, WASE-COVID Investigators
J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print | PMID: 35863542
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Abstract

Fetal Doppler echocardiographic assessment predicts severe postnatal obstruction in total anomalous pulmonary venous connection.

Campbell MJ, White BR, Rychik J, Linder J, ... Tian Z, Cohen MS
Objectives
Obstructed total anomalous pulmonary venous connection (TAPVC) is a form of critical congenital heart disease that usually requires urgent postnatal intervention. Knowing which patients have severe obstruction can aid delivery planning. We previously developed a novel quantitative metric of pulmonary venous flow, the pulmonary venous variability index (PVVI). We hypothesized that fetal PVVI and vertical vein Doppler velocities are associated with severe pulmonary vein obstruction postnatally.
Methods
A retrospective cohort study of neonates with prenatally diagnosed TAPVC was performed. Patients with a fetal echocardiogram performed at the Children\'s Hospital of Philadelphia with Doppler interrogation of the vertical vein were included for analysis. Twenty-nine patients met criteria (21 heterotaxy, 18 supracardiac). The latest gestation fetal echocardiogram was used. Severe pulmonary vein obstruction was defined as preoperative death or urgent surgery or catheter-based intervention (first day of life). Measurements of PVVI, defined as the (maximum velocity - minimum velocity) / mean velocity, were made offline. Wilcoxon ranked sum models were used to assess the association of severe obstruction and PVVI, maximum, mean, and minimum velocity.
Results
The mean gestational age of the latest fetal echocardiogram was 35 weeks (range 30-39 weeks). Twelve of the 29 (41%) met criteria for severe pulmonary vein obstruction. Lower PVVI was associated with greater risk of severe pulmonary venous obstruction (p=0.008). The maximum, mean, and minimum velocity in the vertical vein were all significantly associated with severe pulmonary venous obstruction (p=0.03, p=0.03, and p=0.007, respectively). Qualitative assessment of obstruction was not significantly associated with the outcome. Interobserver reliability for all vertical vein Doppler metrics was high (ICC>0.9).
Conclusion
Fetal PVVI, Vmax, Vmean, and Vmin are associated with severe postnatal pulmonary vein obstruction in TAPVC. Accurate prediction of obstructed TAPVC could allow for safer delivery planning. Further research with larger sample sizes is needed to identify the ideal cut-off value for these Doppler measures.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print
Campbell MJ, White BR, Rychik J, Linder J, ... Tian Z, Cohen MS
J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print | PMID: 35863543
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Abstract

Passive Leg Raise Stress Echocardiography in Severe Paradoxical Low-Flow, Low-Gradient Aortic Stenosis.

Buffle E, Papadis A, Berto MB, Gräni C, Seiler C, de Marchi SF
Background
Dobutamine stress echocardiography (DSE) is used to increase the transvalvular flow in patients with low-flow, low-gradient aortic stenosis. Dobutamine fails to increase the stroke volume index (SVI) in a third of patients. In this study, we tested whether passive leg raise (PLR) added to dobutamine could increase SVI and transvalvular flow in patients with severe paradoxical low-flow, low-gradient aortic stenosis.
Methods
Forty-five patients with apparent severe low-flow, low-gradient AS based on traditional measurements were included. Twenty-five were categorized as belonging to the \"Paradox\"-Group (LVEF≥50%), and twenty to the \"LowEF\"-Group (LVEF<50% or \"classical\" low-flow, low-gradient AS) for comparison. A four-step stress echocardiographic exam was performed: resting conditions (\"Rest\"), PLR alone (\"PLR\"), maximal dobutamine infusion rate (\"Dmax\"), and combination of Dmax and PLR (\"Dmax+PLR\"). AVA, (aortic valve area, cm2) SVI (ml/m2) and mean transvalvular flow (ml/s) were calculated using both, velocity-time-integral (VTI) of LV outflow tract and the Simpson-method. Changes compared to \"Rest\" and between the stress maneuvers were analysed.
Results
In the \"Paradox\"-Group, compared to \"Rest\", LV end-diastolic volume significantly decreased under \"Dmax\" but was completely restored with \"Dmax+PLR\" (\"Rest\", \"Dmax\", \"Dmax+PLR\": 61±15 vs 49±18 (p<0.001) vs 61±18 ml (ns)). The smallest SVI-increase in the \"Paradox\"-Group was observed during \"Dmax\" (\"PLR\", \"Dmax\", \"Dmax+PLR\": VTI: 38±4 (p<0.001), 36±7 (p=0.019), 41±7 (p<0.001); Simpson: 28±6 (p<0.001), 21±7 (ns), 27±7 ml/m2 (ns)). Compared to \"Dmax\", \"Dmax+PLR\" was able to achieve a higher SVI (VTI: 36±7 vs 41±7, p<0.001, Simpson: 21±7 vs 27±7 ml/m2, p<0.001), and transvalvular flow in the Simpson-method only (179±56 vs 219±56 ml/s, p<0.001) as well as, additionally, a higher mean gradient (34±10 vs 39±12 mmHg, p=0.003) and AVA in the Simpson-method (0.64±0.21 vs 0.73±0.21 cm2, p=0.026). In the \"LowEF\"-Group, only SVI VTI (31±8 vs 35±7 ml/m2, p=0.034) and mean gradient (29±12 vs 34±14 mmHg, p=0.003) were higher in \"Dmax+PLR\". The proportion of patients with SVI VTI ≥ 35 ml/m2 and an increase of SVI VTI of more than 20% compared to \"Rest\" was highest in \"Dmax+PLR\" in both groups.
Conclusions
Dobutamine decreases the preload in paradoxical low-flow, low-gradient aortic stenosis. Adding PLR counteracts this effect, resulting in increased SVI and flow (in one method). The combined stress maneuver allowed reclassification of some patients from severe to moderate AS and may therefore be useful in selected cases in this population where the severity is uncertain.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print
Buffle E, Papadis A, Berto MB, Gräni C, Seiler C, de Marchi SF
J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print | PMID: 35863544
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Abstract

Incremental value of myocardial deformation in predicting postnatal coarctation of the aorta: establishment of a novel diagnostic model.

Liu J, Cao H, Zhang L, Hong L, ... Wang J, Xie M
Background
Prenatal detection of coarctation of the aorta (CoA) still suffers from high false-positive and false-negative rates. The objective of this study was to develop a novel model to improve the diagnostic accuracy of fetal CoA.
Methods
A retrospective study was conducted in 122 fetuses with suspected CoA who also had postnatal follow-ups. Fetuses with confirmed diagnosis of CoA after birth were defined as CoA group, and Non-CoA group were those false-positives. Conventional fetal echocardiographic measurements, including great arterial dimensions and flow characteristics were obtained. Left ventricular (LV) functional parameters were determined using two-dimensional speckle tracking echocardiography. A novel multi-parametric diagnostic model, including gestational age (GA) at diagnosis, aortic isthmus (AOI) Z-score and LV longitudinal strain (LVLS), was developed by univariate and multivariate logistic regression analyses. The model was validated prospectively by a validation cohort of 48 fetuses.
Results
CoA was confirmed in 62/122 (50.8%) cases after birth. Fetuses with postnatal CoA were diagnosed significantly earlier than false-positives (median (interquartile range), 24.5 (23.3-26.4) vs 27.8 (24.5-30.4) weeks; P < .001). The Z-scores of aortic dimensions (aortic valve annulus, ascending aorta, transverse aortic arch and AOI) were significantly smaller (all P < .001), while the Z-scores of pulmonary dimensions (pulmonary valve annulus and main pulmonary artery) were significantly greater (all P < .05), in cases of confirmed CoA than false-positives. Compared with Non-CoA group, CoA group displayed lower LV ejection fraction (P = .005), LV fractional area change (P < .001) and LVLS (P < .001). A multivariate logistic regression model incorporating GA (odds ratio (OR): 0.74, 95% confidence interval (CI): 0.60-0.88; P = .001), AOI Z-score (OR: 0.20, 95% CI: 0.08-0.41; P < .001) and LVLS (OR: 1.79, 95% CI: 1.41-2.42; P < .001) was established to diagnose CoA more accurately (Akaike information criterion: 81.77, C-statistics: 0.945). The performance of this model was confirmed prospectively in the validation cohort.
Conclusions
In fetuses with suspected CoA, speckle tracking analysis of LVLS may have an incremental value in predicting postnatal CoA. Our diagnostic model, including GA, AOI Z-score and LVLS, may provide a good tool for the stratification of the risk in fetal CoA and contribute to patient-specific perinatal management.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print
Liu J, Cao H, Zhang L, Hong L, ... Wang J, Xie M
J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print | PMID: 35863545
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Abstract

Prognostic Role of Cardiac Power in a Large Cohort of Patients with Normal Ejection Fraction Referred for Dobutamine Stress Echocardiography.

Anand V, Kane GC, Lee AT, Scott CG, ... Pellikka PA, Pislaru C
Background
Cardiac power reflects cardiac performance in terms of energy transferred by the left ventricle (LV) to the aorta per unit time. Peak stress cardiac power has been shown to predict outcome in patients with reduced LV ejection fraction (EF), and more recently, in patients with normal EF referred for exercise stress echocardiography. We sought to evaluate the prognostic significance of cardiac power in patients with normal EF referred for dobutamine stress test (DSE).
Methods
We studied data from 15,576 patients with EF ≥50% and no significant valvular or right ventricular dysfunction, undergoing DSE. Cardiac power at rest and peak stress and power reserve (peak stress minus rest power) were calculated and normalized to LV mass. Outcome endpoints were all-cause mortality and new-onset heart failure (HF).
Results
The mean age was 66±13 years and 49% patients were females. Resting and peak stress power/mass were 0.7±0.2 and 1.6±0.6 W/100 g of LV myocardium, respectively. During follow-up [median 3.3 (IQR 0.7-7.3) years], 2,278 patients died and 2,137 developed HF. After adjusting for age, sex, comorbidities, and stress test results, lower peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.84, 95% confidence intervals (CI) 0.74-0.95, P=0.004] and HF at follow-up [adjusted HR 0.67, 95% CI 0.59-0.76, P<0.0001]. Power reserve showed similar associations with outcomes.
Conclusion
Assessment of cardiac power during DSE in patients with normal EF provides valuable prognostic information regarding risk of mortality and future HF, in addition to stress test results. It is an important research tool to study cardiac performance and development of risk scores incorporating this novel index could be considered after further validation in prospective studies.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print
Anand V, Kane GC, Lee AT, Scott CG, ... Pellikka PA, Pislaru C
J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print | PMID: 35863546
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Abstract

Prognostic Value of Exercise Stress Echocardiography in Pediatric Cardiac Transplant Recipients.

Perez MT, Rizwan R, Gauvreau K, Daly K, ... Singh TP, Chen MH
Background
Cardiac allograft vasculopathy (CAV) is a leading cause of long-term morbidity and mortality in pediatric heart transplant (HTx) recipients. Exercise stress echocardiography (ESE) has been shown to be useful in the detection of angiographically-confirmed CAD in children. However, the prognostic utility of ESE for prediction of cardiac events in HTx survivors is unknown.
Study aim and hypothesis
Therefore, we aim to assess if an abnormal (positive) ESE will be associated with a higher risk of future cardiovascular (CV) outcomes in pediatric HTx recipients.
Material and methods
We conducted a retrospective review of CV outcomes of a cohort of 95 pediatric HTx recipients who underwent 188 ESE over a 10-year period. A composite endpoint for CV events including myocardial infarction, hospitalization for non-rejection heart failure, coronary revascularization, need for repeat transplantation, and death was used. Based on the interpretation of the ESE results, each ESE study was classified for this study as either positive (abnormal), or negative (normal) for ischemia. Results of the coronary angiograms performed near the time of ESE were also assessed and classified for this study as positive (abnormal) or negative (normal) for CAV according to standard HTx criteria for CAV.
Results
51 (27%) ESE were positive for ischemia. There was a total of 35 CV events in 23 patients. A positive ESE was associated with increased risk of any CV event [Hazard ratio [HR] 3.55, 95% CI 1.52, 8.28, and also an increased risk of CV death (HR 3.19, 95% CI 1.23, 8.28) Freedom from composite CV outcome at 1, 2, and 3 years following a positive ESE was 89.9% (CI = 77.3%, 95.7%), 81.5% (CI = 65.9%, 90.5%), and 63.2% (CI = 41.9%, 78.5%), respectively. Freedom from composite cardiovascular outcome at 1, 2, and 3 years following a negative ESE was 99.3% (94.8, 99.9), 98.4% (93.6, 99.6), and 97.0% (90.6, 99.1) respectively. No patient died within 1 year of a negative ESE.
Conclusions
In this largest study of ESE in pediatric HTx recipients, a positive or abnormal ESE is associated with increased future cardiovascular morbidity and mortality. Conversely, a negative ESE can help predict CV event-free survival. Even in the setting of a normal ANG, our pilot data show that an abnormal ESE may be still clinically important. Use of ESE in follow-up may improve risk stratification and management of pediatric HTx recipients.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print
Perez MT, Rizwan R, Gauvreau K, Daly K, ... Singh TP, Chen MH
J Am Soc Echocardiogr: 18 Jul 2022; epub ahead of print | PMID: 35863548
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Abstract

Mitral Annular Elasticity Determines Severity of Regurgitation in Barlow\'s Disease.

Dumont KA, Dahl Aguilera HM, Persson R, Prot V, Escobar Kvitting JP, Urheim S
Aims
Barlow\'s disease (BD) with late systolic mitral regurgitation provides diagnostic and therapeutic challenges. The mechanisms of the regurgitation are still unclear. We hypothesized that the onset and the severity of late systolic regurgitation are determined by annulus dynamics and the mechanical stresses imposed by the left ventricle.
Methods and results
Ten patients with BD and mitral annulus disjunction (MAD) were compared with ten healthy controls. Resting blood pressure (BP) was measured and transthoracic three-dimensional (3D) echocardiography was analyzed using a holographic display that allows tracking and measurements of mitral annulus surface area (ASA) throughout the cardiac cycle. A novel annulus elastance index (dASA/dP) was calculated between aortic valve opening and onset of mitral regurgitation. Severity of MAD was quantified as the disjunction index (mm*degree). Leaflet coaptation area was calculated using a finite element model. Peak systolic ASA in controls and patients were 9.3±0.6 and 21.1±3.1 cm2, respectively (p<0.001). In patients ASA increased rapidly during LV ejection and onset of mitral regurgitation coincided closely with peak upslope of annulus area change (dASA/dt). The finite element model showed a close association between rapid annulus displacement and coaptation area deficit in BD. Systolic annulus elastance index (0.058±0.036 cm2/mmHg) correlated strongly with disjunction index (r=0.91, p<0.0001). Moreover, regurgitation volume showed a positive correlation with systolic BP (r=0.80, p<0.01)
Conclusion:
The present pilot study supports the hypothesis that annulus dilatation may accentuate mitral valve regurgitation in patients with Barlow\'s disease. A novel annulus elastance index may predict the severity of mitral valve regurgitation in selected patients.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 13 Jul 2022; epub ahead of print
Dumont KA, Dahl Aguilera HM, Persson R, Prot V, Escobar Kvitting JP, Urheim S
J Am Soc Echocardiogr: 13 Jul 2022; epub ahead of print | PMID: 35842077
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Impact:
Abstract

Unsupervised Machine Learning for Assessment of Left Ventricular Diastolic Function and Risk Stratification.

Chao CJ, Kato N, Scott CG, Lopez-Jimenez F, ... Kane GC, Pellikka PA
Background
The 2016 American Society of Echocardiography (ASE) guidelines have been widely used to assess left ventricular diastolic function. However, limitations are present in the current classification system. We aimed to develop a data-driven, unsupervised machine learning approach for diastolic function classification and risk stratification using the left ventricular diastolic function parameters recommended by the 2016 ASE guidelines; the guideline grading was used as the reference standard.
Methods
Baseline demographics, heart failure hospitalization and all-cause mortality data were obtained for all adult patients who underwent transthoracic echocardiography at Mayo Clinic Rochester in 2015. Patients with prior mitral valve intervention, congenital heart disease, cardiac transplant, or cardiac assist device were excluded. Nine left ventricular diastolic function variables (mitral E and A wave peak velocities, E/A, deceleration time, medial and lateral annulus e\' and E/e\', and tricuspid regurgitation peak velocity) were used for an unsupervised machine learning algorithm to identify different phenotype clusters. The cohort average of each variable was used for imputation. Patients were grouped according to the algorithm-determined clusters for Kaplan-Meier survival analysis.
Results
Among 24,414 patients, age 63.6 ±16.2 years, all-cause mortality occurred in 4,612 (18.9%) patients during median follow-up 3.1 years. The algorithm determined 3 clusters with echocardiographic measurement characteristics corresponding to normal diastolic function (n= 8,312), impaired relaxation (n=11,779) and increased filling pressure (n =4,323), with 3-year cumulative mortality of 11.8%, 19.9% and 33.4%, respectively (p<0.0001). All 10,694 (43.8%) patients classified as indeterminate were reclassified into the 3 clusters (3,324, 5,353, and 2,017, respectively) with 3-year mortality of 16.6%, 22.9% and 34.4%, respectively. The clusters also outperformed guideline-based grade for prognostication (c-index: 0.607 vs. 0.582, p=0.013).
Conclusions
Unsupervised machine learning identified physiologically and prognostically distinct clusters based on 9 diastolic function Doppler variables. The clusters can be potentially applied in echocardiography laboratory practice and future clinical trials for simple, replicable diastolic function related risk stratification.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 12 Jul 2022; epub ahead of print
Chao CJ, Kato N, Scott CG, Lopez-Jimenez F, ... Kane GC, Pellikka PA
J Am Soc Echocardiogr: 12 Jul 2022; epub ahead of print | PMID: 35840082
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Impact:
Abstract

A Measurement-Based Protocol Improves Inter-Rater Agreement And Accuracy of Right Ventricular Systolic Pressure Assessment by Echocardiography in Children: A Call for Quality Improvement.

Nawaytou H, Springston C, Lazar A, Keller S, ... Moon-Grady A, Brook M
Background
Echocardiographic measurements carry the promise of improving inter-rater agreement (IR) over subjective assessment. In this study we assess the effect of implementing a measurement-based protocol on the IR agreement and accuracy in reporting of right ventricular (RV) systolic pressure in children. We also evaluate the effect of this reporting protocol on the IR agreement in reporting RV dilation, hypertrophy and systolic function.
Methods
Five echocardiography readers reported their assessment of the RV systolic pressure, dilation, hypertrophy and systolic function on 40 deidentified echocardiograms using their individual accustomed methods and then using an agreed-upon protocol based solely on RV measurements. The IR agreement was assessed using kappa statistics. Accuracy of the RV systolic pressure ratings was assessed using McNemar\'s test in comparison to hemodynamic data obtained by cardiac catheterization. The reliability of the RV measurements was assessed using intraclass correlation coefficient (ICC) and coefficient of variation (CoV).
Results
The IR agreement and accuracy of RV systolic pressure assessment improved after employing the measurement-based protocol [agreement: 0.39 (95% confidence interval: 0.27,0.5) to 0.62 (0.48,0.76) & accuracy 18/40 to 29/40 p = 0.03]. IR agreement of RV dilation improved [0.36 (0.25,0.48) to 0.63 (0.48,0.79)] while the IR agreement of RV hypertrophy [0.29 (0.17,0.42) to 0.35 (0.15,0.55)] and RV systolic function [0.57 (0.45,0.69) to 0.53 (0.41,0.66)] did not improve. The reliability of the measurements was good (ICC > 0.8) except for RV free wall thickness (ICC: 0.62, CoV: 24%) and RV fractional area change (ICC: 0.47, CoV: 22%) proposing a possible reason for lack of improvement in IR agreement of RV hypertrophy and RV systolic function. Heteroscedasticity was observed in the reliability of RV measurements with the ICC being significantly lower at larger magnitudes for all RV measurements.
Conclusions
Standardization of reporting protocols using RV measurements in place of subjective assessment improved IR agreement and accuracy of RV systolic pressure assessment. Reliable measurements, RV systolic pressure and dilation, resulted in improvement in IR agreement while unreliable measurements, RV hypertrophy and systolic function, did not. Special attention to measurements\' reliability and heteroscedasticity of reliability is required when designing clinical protocols to decrease IR disagreement as a source of error.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 12 Jul 2022; epub ahead of print
Nawaytou H, Springston C, Lazar A, Keller S, ... Moon-Grady A, Brook M
J Am Soc Echocardiogr: 12 Jul 2022; epub ahead of print | PMID: 35840083
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Abstract

Three-Dimensional Echocardiography Deconstruction: Feasibility of Clinical Evaluation from 2D Views Derived From a 3D Dataset.

Henry MP, Cotella JI, Slivnick JA, Yamat M, ... Mor-Avi V, Lang RM
Background
Three-dimensional echocardiography (3DE) allows capturing the entire heart in a single dataset that theoretically could be used to extract any 2D views and potentially replace the standard practice of serial 2D acquisitions. We hypothesized that the quality of 3DE-derived 2D images is sufficient to allow visualization of left and right ventricular (LV, RV) and left atrial (LA) endocardium, on par with conventional 2DE images, and potentially more accurate quantification of chamber size and function.
Methods
First, we prospectively studied 36 patients who underwent 2DE imaging in 14 standard views, and full-volume 3DE datasets, from which the same views were extracted offline. The ability to visualize LV endocardium, RV free-wall and LA endocardium was scored. LV linear dimensions, volumes and ejection fraction (EF), LA volume, and RV basal dimension were measured and compared between both types of images. Thereafter, we retrospectively studied 40 patients who underwent 2DE, 3DE and cardiac magnetic resonance (CMR) imaging on the same day. 2DE and 3DE-derived LV volumes and EF were compared side-by-side against CMR reference.
Results
Inter-technique agreement in visualization scores was 87% for LV segments, 86% for RV free-wall, and 83% for LA endocardium. The correlations between 2DE and 3DE-derived measurements were 0.95, 0.97, 0.97 for LV volumes and EF, respectively and 0.88 for RV basal dimension. 3DE-derived measurements of LV volumes and EF were more similar to CMR, than those obtained from conventional 2DE images.
Conclusion
The feasibility of segmental assessment of cardiac chambers using 3DE-derived 2D views is similar to that using conventional 2DE images. This approach provides similar quantitative information, including more accurate LV volumes and EF measurements compared to CMR, and thus promises to significantly shorten the duration of the echocardiographic examination.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 11 Jul 2022; epub ahead of print
Henry MP, Cotella JI, Slivnick JA, Yamat M, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 11 Jul 2022; epub ahead of print | PMID: 35835310
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Abstract

The Association of Severe Tricuspid Regurgitation with Poor Survival is Modified by Right Ventricular Pressure and Function.

Itelman E, Vatury O, Kuperstein R, Ben-Zekry S, ... Guetta V, Maor E
Contemporary data on the independent association of severe TR with excess mortality is warranted.
Objectives
Describe the contemporary outcome of severe TR patients and identify its modifiers.
Methods
Consecutive echocardiographic reports linked to clinical data of the largest medical center in Israel (2007-2019). The primary outcome was all-cause mortality. Cox regression and propensity score matching models were applied.
Results
Final cohort included 97,096 patients. Mild, moderate, and severe TR was documented in 27,147(28%), 2,844(3%) and 1,805 (2%) patients, respectively. During a median follow-up of 5 years [IQR 2-8], 22,170 (23%) patients died. Kaplan-Meier survival analysis demonstrated an increased risk of death with an increasing degree of TR (p Log-rank <.001). Propensity score matching of 1,265 patients with severe TR and their matched controls showed that compared with non-severe TR, patients with severe TR were 17% more likely to die (95% 1.05-1.29 p = .003). The association of severe TR with survival was dependent on estimated right ventricular (RV) pressure, with a more pronounced effect among patients with estimated systolic pressure ≤ 40 mmHg (HR of 2.12 vs. 1.04, p for interaction < .001). A Landmark sub-analysis of 17,967 patients demonstrated that RV function deterioration on a follow-up echocardiographic exam modified the association of severe TR with survival. It was more significant among patients with preserved and stable RV function (p for interaction = 0.035).
Conclusions
The outcome of severe TR is modified by RV pressure and function. Once RV function deteriorates, differences in the outcome of patients with and without severe TR are less pronounced.

Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 08 Jul 2022; epub ahead of print
Itelman E, Vatury O, Kuperstein R, Ben-Zekry S, ... Guetta V, Maor E
J Am Soc Echocardiogr: 08 Jul 2022; epub ahead of print | PMID: 35817379
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Abstract

Power Modulation Echocardiography to Detect and Quantify Myocardial Scar.

Papachristidis A, Theodoropoulos KC, Marvaki A, Queirós S, ... Murgatroyd FD, Monaghan MJ
Background
Myocardial scar correlates with clinical outcomes. Traditionally, late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is used to detect and quantify scar. In this prospective study using LGE CMR as reference, we hypothesized that non-linear ultrasound imaging, namely power modulation, can detect and quantify myocardial scar in selected patients with previous myocardial infarction. In addition, given the different histopathology between ischaemic and non-ischaemic scar, we aimed to test the diagnostic performance of this echocardiographic technique in unselected consecutive individuals with ischaemic and non-ischaemic LGE, or no LGE on CMR.
Methods
71 patients with previous myocardial infarction underwent power modulation echocardiography following a CMR scan (Group A). Subsequently, 101 consecutive patients with or without LGE on CMR, including individuals with non-ischaemic LGE, were scanned with power modulation echocardiography (Group B).
Results
In Group A, echocardiography detected myocardial scar in all 71 patients with good scar volume agreement with CMR (bias -1.9cm3, limits of agreement (LOA) -8.0 to 4.2cm3). On a per-segment basis analysis sensitivity was 82%, specificity 97% and accuracy 92%. Sensitivity was higher in the inferior and posterior segments and lower in the anterior and lateral walls. In Group B, on a per-subject basis analysis the sensitivity of echocardiography was 62% (91% in ischaemic and 30% in non-ischaemic LGE), with specificity and accuracy of 89% and 72% respectively. The bias for scar volume between modalities was 5.9cm3, with LOA 34.6 to 22.9cm3 (bias: -1.9cm3; LOA: -11.4 to 7.6cm3 in ischaemic LGE, and bias: 18.9cm3; LOA: -67.4 to 29.7.6cm3 in non-ischaemic).
Conclusions
Power modulation echocardiography can detect myocardial scar in both selected and unselected individuals with previous myocardial infarction and has good agreement for scar volume quantification with CMR. In an unselected cohort with non-ischaemic LGE, the sensitivity is low.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 04 Jul 2022; epub ahead of print
Papachristidis A, Theodoropoulos KC, Marvaki A, Queirós S, ... Murgatroyd FD, Monaghan MJ
J Am Soc Echocardiogr: 04 Jul 2022; epub ahead of print | PMID: 35798123
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This program is still in alpha version.