<div><h4>Longitudinal Changes in Ventricular Mechanics in Adolescents after the Fontan Operation.</h4><i>Aly S, Mertens L, Friedberg MK, Dragulescu A</i><br /><b>Background</b><br />Ventricular dysfunction is a significant clinical challenge in the long-term follow-up of patients with single ventricle (SV) physiology. Ventricular function and myocardial mechanics can be studied using speckle-tracking echocardiography (STE) which provides information on myocardial deformation. Limited information is available on serial changes in SV myocardial mechanics after the Fontan operation.<br /><b>Aims</b><br />In this study, we wanted to describe serial changes in myocardial mechanics in children after the Fontan operation and the relationship of these changes with myocardial fibrosis markers as obtained by cardiac magnetic resonance (CMR) and exercise performance parameters.<br /><b>Hypothesis</b><br />We hypothesized that ventricular mechanics declines in SV patients over time and is associated with increased myocardial fibrosis and reduced exercise performance.<br /><b>Methods</b><br />Single-center retrospective cohort study including adolescents after the Fontan operation. Ventricular strain and torsion were assessed using STE. CMR and cardiopulmonary exercise testing data closest to the latest echocardiograms were obtained. The most recent follow-up echocardiographic and CMR data were compared to sex and age-matched controls as well as to individual patients\' early post-Fontan data.<br /><b>Results</b><br />50 SV patients (31 LV, 13 RV, and 6 co-dominant) were included. Median time at follow-up echocardiogram from the time of Fontan was 12.8 (10.6-16.6) years. Compared to early post-Fontan echocardiograms, follow-up assessment showed reduced global longitudinal strain [-17.5% (-14.5 to -19.5) vs -19.8% (-16.0 to -21.7), p=0.01], circumferential strain [-15.7% (-11.4 to -18.7) vs -18.9% (-15.2 to -25.0), p=0.009], reduced torsion [1.28˚/cm (0.51 to 1.74) vs 1.72˚/cm (0.92 to 2.34), p= 0.02] with decreased apical rotation but no significant change in basal rotation. Single RVs had lower torsion compared to single LVs [1.04 ˚/cm (0.12 to 2.20) vs 1.25 ˚/cm (0.25 to 2.51), p=0.01]. T1 values were higher in SV compared to controls [1009±36ms vs 958±40ms, p=0.004], and in single RV compared to LV (1023±19ms vs 1006±17ms, p=0.02). T1 correlated circumferential strain (r=0.59, p=0.04) and inversely correlated with O<sub>2</sub> saturation (r=-0.67, p<0.001), and torsion (r=-0.71, p=0.02). Peak oxygen consumption correlated with torsion (r=0.52, p=0.001) and untwist rates (r=0.23, p=0.03) <br /><b>Conclusion:</b><br/>Post Fontan, there is a progressive decrease in myocardial deformation parameters. The progressive decrease in SV torsion is related to a decrease in apical rotation, which is more pronounced in single RVs. Decreased torsion is associated with increased markers of myocardial fibrosis and lower maximal exercise capacity. Torsional mechanics may be an important parameter to monitor after Fontan palliation but further prognostic information is required.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 24 May 2023; epub ahead of print</small></div>

<div><h4>FETAL CARDIAC FUNCTION AT MID-GESTATION AND SUBSEQUENT DEVELOPMENT OF PRE-ECLAMPSIA.</h4><i>Huluta I, Wright A, Mihaela Cosma L, Hamed K, Nicolaides KH, Charakida M</i><br /><b>Objective</b><br />To assess differences in cardiac morphology and function at mid-gestation in fetuses from pregnancies that subsequently developed pre-eclampsia (PE) or gestational hypertension (GH).<br /><b>Methods</b><br />This was a prospective study in 5801 women with singleton pregnancies attending for a routine ultrasound examination at mid-gestation, including 179 (3.1%) who subsequently developed PE and 149 (2.6%) who developed GH. Conventional and more advanced echocardiographic modalities, such as speckle tracking, were used to assess fetal cardiac function in the right and left ventricle. The morphology of the fetal heart was assessed by calculating the right and left sphericity index.<br /><b>Results</b><br />In fetuses from the PE group (vs. the no PE or GH group) there was a significantly higher left ventricular global longitudinal strain and lower left ventricular ejection fraction which could not be accounted for by fetal size. All other indices of fetal cardiac morphology and function were comparable between groups. There was no significant correlation between fetal cardiac indices and uterine artery pulsatility index (UtA-PI) multiple of the median (MoM) or placental growth factor (PlGF) MoM.<br /><b>Conclusion</b><br />At mid-gestation, fetuses of mothers at risk of developing PE, but not those at risk of GH, have mild reduction in left ventricular myocardial function. Although absolute differences were minimal and most likely not clinically relevant, these may suggest an early programming effect on left ventricular contractility in fetuses of mothers who develop PE.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 23 May 2023; epub ahead of print</small></div>

<div><h4>Association between segmental non-invasive myocardial work and microvascular perfusion in ST-segment elevation myocardial infarction: implications for left ventricular functional recovery and clinical outcomes.</h4><i>Sun S, Chen N, Sun Q, Wei H, ... Xie F, R PT</i><br /><b>Background</b><br />Predicting left ventricular recovery (LVR) after acute ST-segment elevation myocardial infarction (STEMI) is of prognostic importance. This study aims to explore the prognostic implications of segmental noninvasive myocardial work (MW) and microvascular perfusion (MVP) after STEMI.<br /><b>Methods</b><br />In this retrospective study, 112 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) and transthoracic echocardiography after PCI were enrolled. MVP was analyzed by myocardial contrast echocardiography (MCE), and segmental MW was analyzed by noninvasive pressure-strain loops. 671 segments with abnormal function at baseline were analyzed. The degrees of MVP were observed following intermittent high-mechanical index impluses: replenishment within 4 sec (normal MVP, nMVP), replenishment >4 sec and within 10 sec (delayed MVP, dMVP), persistent defect (microvascular obstruction, MVO). The correlation between MW and MVP was analyzed. The correlation of the MW and MVP with LVR (normalization of wall thickening, >25%) was assessed. The prognostic value of segmental MW and MVP for cardiac events (cardiac death, admission for congestive heart failure or recurrent myocardial infarction) were evaluated.<br /><b>Results</b><br />NMVP was seen in 70 segments, dMVP in 236, and MVO in 365. The sMW indices were independently correlated with MVP. 244 (36.4%) segments had segmental LVR at 3 month follow-up. Segmental myocardial work efficiency (sMWE) and MVP were independently associated with segmental LVR (P<0.05). The χ<sup>2</sup> of combination of sMWE and MVP was higher than either index alone for identifying segmental LVR (P<0.001). At a median follow-up of 42.0 months, cardiac events occurred in 13 patients; all regional MW parameters, high sensitivity troponin I (hs-TNI), regional longitudinal strain (rLS), et al were associated with cardiac events.<br /><b>Conclusion</b><br />SMW indices are associated with MVP within the infarct zone following reperfused STEMI. Both were independently associated with segmental LVR , and regional MW was associated with cardiac events , providing prognostic value in STEMI patients.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 22 May 2023; epub ahead of print</small></div>

<div><h4>Echocardiographic Evaluation of Pulmonary Embolism : A Review.</h4><i>Nasser MF, Jabri A, Limaye S, Sharma S, ... Aneja A, Gandhi S</i><br /><AbstractText>Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 18 May 2023; epub ahead of print</small></div>

<div><h4>Pearls and Pitfalls in the Transesophageal Echocardiographic Diagnosis of Patent Foramen Ovale.</h4><i>Song JK</i><br /><AbstractText>Large randomized controlled trials have shown the benefits of percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke and PFO. Recent studies have highlighted the clinical significance and prognostic implication of various anatomical features of PFO and the adjacent atrial septum, such as atrial septal aneurysm (ASA), PFO size, large shunt, and hypermobility. Transthoracic echocardiography with contrast study is used for the indirect diagnosis of PFO, as it reveals the passage of the contrast into the left atrium. In contrast, transesophageal echocardiography (TEE) offers a direct demonstration of PFO by measuring its size using the maximum separation distance between the septum primum and septum secundum. Furthermore, TEE enables the acquisition of detailed anatomical features of the adjacent atrial septum including ASA, hypermobility, and PFO tunnel length, which carry significant prognostic implications. TEE also facilitates the diagnosis of pulmonary arteriovenous malformation, a relatively rare cause of paradoxical embolism. This review provides evidence for supporting TEE as a useful screening test for patients with cryptogenic stroke to identify suitable candidates for percutaneous device closure of PFO. Additionally, cardiac imaging specialists with proficiency in comprehensive TEE examination should be part of the heart-brain team for proper evaluation of and decision-making in patients with cryptogenic stroke.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 15 May 2023; epub ahead of print</small></div>

<div><h4>Reduced Left Atrial Appendage Flow Is Associated With Future Atrial Fibrillation After Cryptogenic Stroke.</h4><i>Dhont S, Wouters F, Deferm S, Bekelaar K, ... Vandervoort P, Bertrand PB</i><br /><b>Background</b><br />Hemostasis within the left atrial appendage (LAA) is a common cause of stroke, especially in patients with atrial fibrillation (AF). Although LAA flow provides insights into LAA function, its potential for predicting AF has yet to be established. The aim of this study was to explore whether LAA peak flow velocities early after cryptogenic stroke are associated with future AF on prolonged rhythm monitoring.<br /><b>Methods</b><br />A total of 110 patients with cryptogenic stroke were consecutively enrolled and underwent LAA pulsed-wave Doppler flow assessment using transesophageal echocardiography within the early poststroke period. Velocity measurements were analyzed offline by an investigator blinded to the results. Prolonged rhythm monitoring was conducted on all participants via 7-day Holter and implantable cardiac monitoring devices, with follow-up conducted over a period of 1.5 years to determine the incidence of AF. The end point of AF was defined as irregular supraventricular rhythm with variable RR interval and no detectable P waves lasting ≥30 sec during rhythm monitoring.<br /><b>Results</b><br />During a median follow-up period of 539 days (interquartile range, 169-857 days), 42 patients (38%) developed AF, with a median time to AF diagnosis of 94 days (interquartile range, 51-487 days). Both LAA filling velocity and LAA emptying velocity (LAAev) were lower in patients with AF (44.3 ± 14.2 and 50.7 ± 13.3 cm/s, respectively) compared with patients without AF (59.8 ± 14.0 and 76.8 ± 17.3 cm/sec, respectively; P < .001 for both). LAAev was most strongly associated with future AF, with an area under the receiver operating characteristic curve of 0.88 and an optimal cutoff value of 55 cm/sec. Age and mitral regurgitation were independent determinants of reduced LAAev.<br /><b>Conclusions</b><br />Impaired LAA peak flow velocities (LAAev < 55 cm/sec) in patients with cryptogenic stroke are associated with future AF. This may facilitate the selection of appropriate candidates for prolonged rhythm monitoring to improve its diagnostic accuracy and implementation.<br /><br />Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Soc Echocardiogr: 15 May 2023; epub ahead of print</small></div>

<div><h4>A Multimodality Imaging Approach to Defining Risk in Patients With Acute Pulmonary Embolism.</h4><i>Shah S, Ogbonna AV, Nance J, Gregoski MJ, ... Todoran T, Litwin SE</i><br /><b>Background</b><br />Morbidity and mortality for acute pulmonary embolism (PE) remain high. Therapies such as catheter directed thrombolysis may improve outcomes but these are generally reserved for higher-risk patients. Imaging may help guide the use of the newer therapies, but current guidelines focus more on clinical factors. Our goal was to create a risk model that incorporated quantitative echocardiographic and computed tomography (CT) measures of right ventricular (RV) size and function, thrombus burden and serum biomarkers of cardiac overload or injury.<br /><b>Methods</b><br />Retrospective study of 150 patients evaluated by a PE response team. Echocardiography was performed within 48 hours of diagnosis. CT measures included RV/LV ratio and thrombus load (Qanadli score). Echocardiography was used to obtain various quantitative measures of right ventricular (RV) function. We compared characteristics of those who met the primary endpoint (7-day mortality and clinical deterioration) to those who did not. Receiver Operating Curve analysis was used to assess the performance of different combinations of clinically relevant features and the association with adverse outcomes.<br /><b>Results</b><br />52% were female, age 62±17, systolic blood pressure 123±25mmHg, heart rate 98±19, troponin 3.2±35 ng/dl and BNP 467± 653). Fourteen (9.3%) were treated with systemic thrombolytics, 27 (18%) underwent catheter-directed thrombolytics, 23 (15%) were intubated or required vasopressors and 14 (9.3%) died. Patients who met the primary endpoint (44%) vs. those who did not (56%), had lower RV S\' (6.6 vs. 11.9 cm/s (p<0.001)) and RV free wall strain (-10.9% vs. -13.6% (p=0.005), higher RV/LV ratio on CT and higher serum BNP and troponin levels. ROC analysis demonstrated an AUC of 0.89 for a model that included RV S\', RVFWS and TAPSE/RVSP ratio from echo, thrombus load and RV/LV ratio from CT, and troponin and BNP levels.<br /><b>Conclusions</b><br />A combination of clinical, echo and CT findings that reflect the hemodynamic effects of the embolism identified patients with adverse events related to the acute PE. Optimized scoring systems that focus on reversible abnormalities attributable to the PE may allow more appropriate triaging of intermediate to high-risk patients with PE for early interventional strategy.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 11 May 2023; epub ahead of print</small></div>

<div><h4>A Practical Approach to Echocardiographic Imaging in Patients with Hypertrophic Cardiomyopathy.</h4><i>Mitchell CC, Frye C, Jankowski M, Symanski J, ... Nagueh SF, Phelan D</i><br /><AbstractText>Hypertrophic cardiomyopathy (HCM) is frequently unrecognized or misdiagnosed. The recently published consensus recommendations from the American Society of Echocardiography provided recommendations for the utilization of multimodality imaging in the care of patients with HCM. This document provides an additional practical framework for optimal image and measurement acquisition and guidance on how to tailor the echocardiography examination for individuals with HCM. It also provides resources for physicians and sonographers to use to develop HCM imaging protocols.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 07 May 2023; epub ahead of print</small></div>

<div><h4>Normal Values of 3D Right Ventricular Size and Function Measurements: Results of the World Alliance of Societies of Echocardiography Study.</h4><i>Addetia K, Miyoshi T, Amuthan V, Citro R, ... Lang RM, WASE Investigators</i><br /><b>Background</b><br />Normal values for 3D right ventricular (RV) size and function are not well established, as they originate from small studies that involved predominantly white North American and European populations, did not use RV-focused views and relied on older 3D RV analysis software . The World Alliance of Societies of Echocardiography (WASE) study was designed to generate reference ranges for normal subjects around the world. In this study, we sought to assess the world-wide capability of 3D imaging of the right ventricle and report size and function measurements, including their dependency on age, sex and ethnicity.<br /><b>Methods</b><br />Healthy subjects free of cardiac, pulmonary and renal disease were prospectively enrolled at 19 centers in 15 countries, including 6 continents. 3D wide-angle RV datasets were obtained and analyzed using dedicated RV software (Tomtec) to measure end-diastolic and end-systolic volumes (EDV, ESV), stroke volume (SV) and ejection fraction (EF). Results were categorized by sex, age (18-40, 41-65 and >65 years) and ethnicity.<br /><b>Results</b><br />Of the 2007 subjects with attempted 3D RV acquisitions, 1051 had adequate image quality for confident measurements. Upper and lower limits for BSA-indexed EDV (mL/m<sup>2</sup>) and ESV (mL/m<sup>2</sup>) and EF (%) were [48, 95], [19, 43] and [44, 58] for men and [42, 81], [16, 36] and [46, 61] for women. Men had significantly larger EDV, ESV and SV (even after BSA indexing) and lower EF than women (p<0.05). EDV and ESV did not show any meaningful differences between age groups. 3D RV volumes were smallest in Asians.<br /><b>Conclusions</b><br />Reliability of 3D RV acquisition is low worldwide underscoring the importance for future improvements in imaging techniques. Sex and race must be taken into consideration in the assessment of both RV volumes and EF.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>The risk of heart failure progression in patients with patent foramen ovale: differential risk associated with device closure.</h4><i>Park J, An SY, Choi HM, Hwang IC, ... Park JH, Cho GY</i><br /><b>Background</b><br />A patent foramen ovale (PFO) can unload left atrial pressure via an interatrial shunt. We investigated whether device closure of PFO is associated with a subsequent risk of heart failure (HF), particularly in patients with structural heart disease or atrial fibrillation (AF).<br /><b>Methods</b><br />We enrolled 4,804 consecutive patients who underwent transesophageal echocardiography at tertiary medical centers in Korea between 2007 and 2019. The primary outcome was the 4-year risk of HF hospitalization. Underlying structural heart disease was determined by echocardiography.<br /><b>Results</b><br />PFO was observed in 981 (20.4%) patients, where 161 underwent device closure. During follow-up (median 3.5 [1.4-6.4] years), the primary outcome was lower in patients with PFO than in those without (2.6 vs. 4.0%, adjusted hazard ratio [aHR] 0.65, 95% confidence interval [CI] 0.45-0.94, p=0.021). Among the patients with PFO, the primary outcome was higher in the device closure group than in the no-closure group (5.5 vs. 1.2%, aHR: 5.59, 95% CI 4.26-7.34, p<0.001). Consistent result was found in patients with structural heart disease or AF (9.6 vs. 3.9%, aHR 2.55, 95% CI 1.95-3.33, p<0.001), demonstrating an increased risk of the primary outcome proportionate to the number of combined structural abnormalities. However, no significant association was observed between the primary outcome and PFO closure in those without structural heart disease or AF (1.7 vs. 1.5%, aHR 1.22, 95% CI 0.99-1.50, p=0.054).<br /><b>Conclusions</b><br />Patients with underlying structural heart disease or AF may be predisposed to symptomatic HF progression after PFO closure. Therefore, careful medical surveillance with optimal risk management is needed in these patients.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 15 Apr 2023; epub ahead of print</small></div>

<div><h4>Diagnostic Accuracy of Transesophageal Echocardiographic Commissural-Biplane Approach in Identifying Mitral Valve Anatomy.</h4><i>Abazid RM, Frost A, Manian U, Patil N, ... Chu MW, Tzemos N</i><br /><b>Background</b><br />Transesophageal echocardiography (TEE) conventional multiplane approach (MPA) and the newly proposed commissural biplane approach (CBA) are the recommended algorithms for identifying the affected mitral valve (MV) segments in the setting of mitral regurgitation. To date, there are no reports to address the diagnostic performance of CBA. In this study we aim to analyze the diagnostic accuracy of CBA and MPA in comparison to three-dimensional echocardiographic findings in patients with severe mitral regurgitation.<br /><b>Methods</b><br />We prospectively enrolled 102 patients with severe mitral regurgitation. All patients underwent systematic TEE assessment of MV before surgical intervention to define the affected MV segments/scallops. The standard MPA includes 4-chamber (4-CH), 2-CH, long-axis and commissural views; CBA was performed through obtaining bi-commissural view and simultaneous biplane imaging of the medial, middle and lateral MV aspects. The findings of both TEE approaches were compared to 3D-TEE data in order to assess the diagnostic accuracy of MPA and CBA.<br /><b>Results</b><br />Patients\' mean age was (65±11) years; 37 (36.3%) were female. We found that CBA had an overall diagnostic accuracy between 88% to 97% in identifying the abnormal MV scallops; in contrast, MPA accuracy ranged between 82% to 95%. CBA and MPA were least accurate in identifying P3 scallop 88% and 82% respectively; whereas, both were most accurate in assessing A2 segment 95% and 97%. The sensitivity of identifying commissural abnormalities was 80% with CBA and 30% with MPA. 3D-TEE found to have a strong agreement with CBA (averaged kappa of 0.81, P < 0.0001) and a modest agreement with MPA (averaged kappa of 0.61, P < 0.0001) in identifying abnormal anterior or posterior segments. On the other hand, 3D-TEE had a weak agreement with CBA (kappa of 0.43, P < 0.0001), and no agreement with MPA (kappa of 0.14, P= 0.153) in assessment of commissural involvements.<br /><b>Conclusion</b><br />Commissural biplane approach is more accurate than MPA in the assessment of MV commissural involvement. Given the accuracy differences of the two approaches for specific leaflet/scallops, a comprehensive evaluation using both approaches is recommended for all MV scallops assessments.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 15 Apr 2023; epub ahead of print</small></div>

<div><h4>Association of gestational age at birth with left cardiac dimensions at near term corrected age among extremely preterm infants.</h4><i>Moore SS, De Carvalho Nunes G, Villegas Martinez D, Dancea A, ... Sant\'Anna G, Altit G</i><br /><b>Background</b><br />Remodelling and altered ventricular geometry have been described in premature-born adults. Although they seem to have an adverse cardiac phenotype, the impact of various degrees of prematurity on cardiac development has been scarcely reported. In this study, we evaluated the impact of gestational age (GA) at birth on cardiac dimensions and function at near term age among extremely preterm infants.<br /><b>Methods</b><br />Retrospective single center cohort study of infants born <29 weeks GA between 2015-2019. Infants with available clinically acquired echocardiography between 34-43 weeks were included. Two groups were investigated: born <26 weeks or ≥26 weeks. All measurements were done by an expert masked to clinical data, using the raw images. The primary outcome was measurements of cardiac dimensions and function based on GA group. Secondary outcomes were the association between cardiac dimensions and post-natal steroid exposure, and with increments of GA at birth.<br /><b>Results</b><br />A total of 205 infants were included (<26 weeks n=102, ≥26 weeks n=103). At time of echocardiography, weight (2.4 ±0.5 vs 2.5 ±0.5 kg, p=0.86) and age (37.2 ±1.6 vs 37.1 ±1.9 weeks, p=0.74) were similar between groups. There was no difference in metrics of right-sided dimensions and function. However, left-sided dimensions were decreased in infants born <26 weeks, including systolic left ventricle (LV) diameter (1.06 ±0.20 cm vs 1.12 ±0.18 cm, p=0.02), diastolic LV length (2.85 ±0.37 vs 3.02 ±0.57 cm, p=0.02), and estimated LV end diastolic volume (EDV) (5.36 ±1.69 vs 6.01 ±1.79 mL, p=0.02).<br /><b>Conclusions</b><br />In our cohort of very immature infants, birth at the extreme of prematurity was associated with smaller left cardiac dimensions around 36 weeks of corrected age. Future longitudinal prospective studies should evaluate further the impact of prematurity on LV development and performance, and their long-term clinical impact.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 10 Apr 2023; epub ahead of print</small></div>

<div><h4>Evaluation of Pericardial Thickening and Adhesion using High Frequency Ultrasound.</h4><i>Lin J, Li M, Huang Y, Yuan Y, ... Wei Y, Huang X</i><br /><b>Background</b><br />Routine echocardiography using a standard frequency ultrasound (SFU) probe has insufficient spatial resolution to clearly visualize the parietal pericardium (PP). High frequency ultrasound (HFU) has an enhanced axial resolution. This study aimed to use commercially available high frequency linear probe (HFLP) to evaluate the apical PP thickness (PPT) and pericardial adhesion (PA) in both normal pericardium and/or pericardial diseases.<br /><b>Methods</b><br />From April 2002 to March 2022, 227 healthy individuals, 205 patients with apical aneurysm (AA) and 80 patients with chronic constrictive pericarditis (CP) were recruited to participate in this study. All subjects received both SFU and HFU to image the apical PP (APP) and pericardial adhesion (PA). Some subjects received CT scans.<br /><b>Results</b><br />The apical PPT was measured by HFU and found to be 0.60±0.01 (0.37∼0.87) mm in normal controls, 1.22±0.04 (0.48∼4.53) mm in patients with AA, and 2.91±0.17 (1.13∼9.01) mm in patients with CP. A tiny physiologic effusion was observed in 39.2% of normal individuals. PA was detected in 69.8% of patients with local pericarditis of AA and 97.5% of patients with CP. Visibly thickened visceral pericardium was observed in six CP patients. The apical PPT measurements obtained by HFU correlated well with those obtained by CT in those CP patients. However, CT could only clearly visualize the APP in 45% of normal individuals and 37% of patients with AA. In 10 patients with CP, both HFU and CT demonstrated equal ability to visualize the very thickened APP.<br /><b>Conclusions</b><br />The apical PPTs measured by HFU in normal controls was 0.40∼1.00 mm, consistent with previous reports from necropsy studies. HFU had a higher resolution in distinguishing local pericarditis of the APP from normal individuals. We found that HFU was superior to CT in imaging APP lesions, as CT failed to visualize APP in more than half of both normal individuals and patients with AA. The fact that all 80 patients with CP in our study had significantly thickened APP raises doubt regarding the previously reported findings that 18% of CP patients had normal PPT.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 03 Apr 2023; epub ahead of print</small></div>

<div><h4>Fully Automated Artificial Intelligence Assessment of Aortic Stenosis by Echocardiography.</h4><i>Krishna H, Desai K, Slostad B, Bhayani S, ... Frazin L, Kansal M</i><br /><b>Background</b><br />Aortic stenosis (AS) is a common form of valvular heart disease, present in over 12% of the population aged 75 years and above<sup>1</sup>. Transthoracic echocardiography (TTE) is the first line of imaging in the adjudication of AS severity but is time consuming and requires expert sonographic and interpretation capabilities to yield accurate results. Artificial intelligence (AI) technology has emerged as a useful tool to address these limitations but has not yet been applied in a fully hands-off manner to evaluate AS. Here, we correlate artificial neural network measurements of key hemodynamic AS parameters to experienced human reader assessment.<br /><b>Methods</b><br />2-dimensional and Doppler echocardiographic images from patients with normal aortic valves and all degrees of AS were analyzed by an artificial neural network (Us2.ai, Singapore) with no human input to measure key variables in AS assessment. Trained echocardiographers blinded to AI data performed manual measurements of these variables, and correlation analyses were performed.<br /><b>Results</b><br />Our cohort included 256 patients with an average age of 67.6 ± 9.5 years. Across all AS severities, AI closely matched human measurement of aortic valve peak velocity (r = 0.97, p < 0.001), mean pressure gradient (r = 0.94, p < 0.001), aortic valve area by continuity equation (r = 0.88, p < 0.001), stroke volume index (r = 0.79, p < 0.001), left ventricular outflow tract velocity time integral (r = 0.89, p < 0.001), aortic valve velocity time integral (r = 0.96, p < 0.001), and left ventricular outflow tract diameter (r = 0.76, p < 0.001).<br /><b>Conclusions</b><br />Artificial neural networks have the capacity to closely mimic human measurement of all relevant parameters in the adjudication of AS severity. Application of this AI technology may minimize inter-scan variability, improve interpretation and diagnosis of AS, and allow for precise and reproducible identification and management of patients with aortic stenosis.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 21 Mar 2023; epub ahead of print</small></div>

<div><h4>Unsupervised Time Series Clustering of Left Atrial Strain for Cardiovascular Risk Assessment.</h4><i>Ntalianis E, Sabovčik F, Cauwenberghs N, Kouznetsov D, ... Claus P, Kuznetsova T</i><br /><b>Aims</b><br />Early identification of individuals at high risk of developing cardiovascular (CV) events is of paramount importance for efficient risk management. Here, we investigated whether employing unsupervised machine learning methods on time series data of left atrial (LA) strain could distinguish clinically meaningful phenogroups associated with the risk of developing adverse events.<br /><b>Methods</b><br />In 929 community-dwelling individuals (mean age, 51.6 years; 52.9% women), we acquired clinical and echocardiographic data, including LA strain traces, at baseline and collected cardiac events on average 6.3 years later. We employed two unsupervised learning techniques: (i) an ensemble of Deep Convolutional Neural Network Autoencoder (AE) with k-medoids and (ii) Self-Organizing Map to cluster spatiotemporal patterns within LA strain curves. Clinical characteristics and cardiac outcome were used to evaluate the validity of the k clusters using the original cohort, while an external population cohort (n=378) was used to validate the trained models.<br /><b>Results</b><br />In both approaches the optimal number of clusters was 5. The first three clusters had differences in sex distribution and heart rate, but had a similar low CV risk profile. On the other hand, cluster 5 had the worst CV profile and a higher prevalence of left ventricular remodeling and diastolic dysfunction compared to other clusters. The respective indexes of cluster 4 were in between those of clusters 1-3 and 5. After adjustment for traditional risk factors, cluster 5 had the highest risk of cardiac events as compared to cluster 1, 2 and 3 (HR: 1.36; 95%CI:1.09‒1.70; P=0.0063). Similar LA strain patterns were obtained when the models were applied to the external validation cohort, and clinical characteristics revealed similar CV risk profiles across all clusters.<br /><b>Conclusion</b><br />Unsupervised machine learning algorithms employed in time series LA strain curves identified clinically meaningful clusters of LA deformation and provide incremental prognostic information over traditional risk factors.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 21 Mar 2023; epub ahead of print</small></div>

<div><h4>Deep Learning for Improved Precision and Reproducibility of Left Ventricular Strain in Echocardiography: A Test-Retest Study.</h4><i>Salte IM, Østvik A, Olaisen SH, Karlsen S, ... Lovstakken L, Grenne B</i><br /><b>Aims</b><br />Assessment of left ventricular (LV) function by echocardiography is hampered by modest test-retest reproducibility. A novel artificial intelligence (AI) method based on deep learning provides fully automated measurements of LV global longitudinal strain (GLS) and may improve the clinical utility of echocardiography by reducing user related variability. The aim of this study was to assess within-patient test-retest reproducibility of LV GLS measured by the novel AI method in repeated echocardiograms recorded by different echocardiographers, and further, to compare the results to manual measurements.<br /><b>Methods and results</b><br />Two test-retest datasets (n=40 and n=32) were obtained at separate centers. Repeated recordings were acquired in immediate succession by two different echocardiographers at each center. For each dataset, four readers measured GLS in both recordings using a semi-automatic method to construct test-retest inter-reader and intra-reader scenarios. Agreement, mean absolute difference and minimal detectable change (MDC) were compared to analyses by AI. In a subset of 10 patients, beat-to-beat variability in three cardiac cycles was assessed by two readers and AI. Test-retest variability was lower with AI compared to inter-reader scenarios (dataset I: MDC 3.7 vs 5.5, mean absolute difference 1.4 vs 2.1; dataset II: MDC 3.9 vs 5.2, mean absolute difference 1.6 vs 1.9, all p<0.05). There was bias in GLS measurements in 13 of 24 test-retest inter-reader scenarios (largest bias 3.2 strain units). In contrast, there was no bias in measurements by AI. Beat-to-beat MDCs were 1,5, 2.1, and 2.3 for AI and the two readers, respectively. Processing time for analyses of GLS by the AI method was 7.9±2.8 seconds.<br /><b>Conclusion</b><br />A fast AI method for automated measurements of LV GLS reduced test-retest variability and removed bias between readers in both test-retest datasets. By improving the precision and reproducibility, AI may increase the clinical utility of echocardiography.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Right Ventricular Strain in Patients with Ductal Dependent Tetralogy of Fallot.</h4><i>Keelan J, Pasumarti N, Crook S, Decost G, ... Mercer-Rosa L, DiLorenzo M</i><br /><b>Background</b><br />Right ventricular (RV) dysfunction is an independent predictor of poor outcomes in patients with tetralogy of Fallot (TOF) and global longitudinal strain (GLS) is a well-validated echocardiographic technique to measure RV function. While trends in RV GLS have been examined in patients with TOF they have not been studied specifically in ductal dependent TOF, a group in which there is not a clear consensus on the best surgical strategy. We sought to assess the mid-term trajectory of RV GLS in ductal dependent TOF patients, drivers of this trajectory, and differences in RV GLS between repair strategies.<br /><b>Methods</b><br />This was a retrospective two-center cohort study of patients with ductal dependent TOF who underwent repair. Ductal dependence was defined as being initiated on prostaglandin therapy and/or undergoing surgical intervention on or before 30 days of life. RV GLS was measured on echocardiograms pre-operatively, early post-complete repair, and at one and two years of age. RV GLS was trended over time and compared between surgical strategies and with controls. Mixed-effects linear regression models were used to evaluate the factors associated with changes in RV GLS over time.<br /><b>Results</b><br />Forty-four ductal dependent TOF patients were included in the study, of which 33 (75%) underwent primary complete repair and 11 (25%) underwent staged repair. Complete TOF repair was performed at a median of 7 days in the primary repair group and 178 days in the staged repair group. RV GLS improved over time from the post-complete repair echocardiogram through two years of age (-17.4% (IQR: -15.5% to -18.9%) vs -21.5% (IQR: -18.0% to -23.3%) p<0.001). However, compared to aged matched controls, subjects had worse RV GLS at all time points. There was no difference in RV GLS between the staged and primary complete repair groups at two year follow up. Shorter intensive care unit (ICU) length of stay (LOS) after complete repair was independently associated with improvement in RV GLS over time. Strain improved by 0.07% (95% CI: 0.01 to 0.12) for every one less ICU day (p=0.03).<br /><b>Conclusions</b><br />RV GLS improves over time amongst patients with ductal dependent TOF, though is consistently reduced compared to controls, suggesting an altered deformation pattern in ductal dependent TOF patients. There was no difference in RV GLS between the primary and staged repair groups at mid-term follow up suggesting that repair strategy is not a risk factor for worse RV strain in the mid-post-operative period. A shorter complete repair ICU LOS is associated with an improved trajectory of RV GLS.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Contraction Patterns of Post-Fontan Single Right Ventricle versus Normal Left and Right Ventricles in Children: Insights from Principal Strain Analysis.</h4><i>Sato T, Matsubara D, Wang Y, Agger P, Pedrizzetti G, Banerjee A</i><br /><b>Background</b><br />Principal strain analysis (PSA) quantifies three-dimensional (3D) myocardial deformation using 3D speckle tracking echocardiography. It defines both amplitude and direction of the principal myocardial contraction, expressed as principal strain (PS), and a perpendicular secondary strain (SS) of lower intensity. We aim to apply PSA to describe the contractile pattern in the single right ventricle (SRV) functioning as a systemic chamber in hypoplastic left heart syndrome (HLHS), compared with normal left ventricle (LV) and right ventricle (RV), and to compare SRV function with conventional echocardiographic evaluations.<br /><b>Methods</b><br />Sixty-four post-Fontan HLHS patients and age-matched controls (LV: 64, RV: 48) underwent computation of PS-lines, ejection fraction (EF), end-diastolic volume indexed by body surface area (EDVi), PS, SS, circumferential strain (CS), and longitudinal strain (LS). The PS-lines were compared between groups. Linear regressions with coefficient determination (R<sup>2</sup>) of strains, fractional area change (FAC), and tricuspid annular plane excursion with EF and EDVi were assessed in SRV. Additionally, HLHS cohort was equally divided into two groups, higher and lower EF groups, followed by comparison of all parameters.<br /><b>Results</b><br />The pattern of PS-lines demonstrated a left-handed direction in anterior free wall, a right-handed direction in posterior free wall, and a circumferential direction in medial wall in SRV. In contrast, in the normal LV the principal contraction is in the circumferential direction whereas in the normal RV it is predominantly longitudinal. R<sup>2</sup> of PS, SS, and CS on EF were high (0.88, 0.72, and 0.90, respectively), whereas R<sup>2</sup> of LS was comparable with FAC (0.56 and 0.55). All parameters were independent of EDVi. PS-lines of higher EF group showed a more circumferential orientation than lower EF group in SRV.<br /><b>Conclusions</b><br />PSA provides a unique functional map of SRV contraction. This map differs from corresponding maps of normal LV and RV. This may be helpful in understanding the mechanisms of SRV function, although future longitudinal studies are needed.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 15 Mar 2023; epub ahead of print</small></div>

<div><h4>The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices.</h4><i>Peck D, Rwebembera J, Nakagaayi D, Minja NW, ... Okello E, Sable C</i><br /><b>Introduction</b><br />A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic (echo) images holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of non-experts to obtain diagnostic quality images in patients with RHD using AI guidance with color Doppler.<br /><b>Methods</b><br />Novice providers without prior ultrasound experience underwent a one-day training curriculum to complete a 7-view screening protocol using AI guidance in Kampala, Uganda. All trainees then scanned 8-10 volunteer patients using AI guidance, half RHD and half normal. The same patients were scanned by two expert sonographers without the use of AI guidance. Images were evaluated by expert blinded cardiologists to assess (1) diagnostic quality to determine presence/absence of RHD, (2) valvular function, and (3) ACEP score 1-5 for each view.<br /><b>Results</b><br />Thirty-six novice participants scanned a total of 50 patients resulting in a total of 462 echocardiogram studies, 362 obtained by non-experts using AI guidance and 100 obtained by expert sonographers without AI guidance. Novice images enabled diagnostic interpretation in > 90% of studies for presence/absence of RHD, abnormal MV morphology and mitral regurgitation (vs 99% by experts, p=<0.001). Images were less diagnostic for aortic valve disease (79% for aortic regurgitation, 50% for aortic stenosis, vs 99% and 91% by experts, p<0.001). The ACEP scores of non-expert images were highest in the parasternal long axis images (mean 3.45, 81% ≥ 3) compared to lower scores for apical 4 (mean 3.20, 74% ≥3), and apical 5 images (mean 2.43, 38% ≥ 3).<br /><b>Conclusions</b><br />AI guidance with color Doppler is feasible to enable rheumatic heart disease screening by non-experts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 09 Mar 2023; epub ahead of print</small></div>