Journal: J Am Soc Echocardiogr

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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

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

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

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

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

Machine Learning for Pediatric Echocardiographic Mitral Regurgitation Detection.

Edwards LA, Feng F, Iqbal M, Fu Y, ... Sable C, Luo J
Background
Echocardiography-based screening for valvular disease in at-risk asymptomatic children can result in early diagnosis. These screening programs, however, are resource intensive, and may not be feasible in many resource-limited settings. Automated echocardiographic diagnosis may enable more widespread echocardiographic screening, early diagnosis, and improved outcomes. In this feasibility study, we sought to build a machine learning model capable of identifying mitral regurgitation (MR) on echocardiogram.
Methods
Echocardiograms were labeled by clip for view and by frame for the presence of MR. The labeled data were used to build two convolutional neural networks (CNNs) to perform the stepwise tasks of classifying the clips 1) by view and 2) by the presence of any MR, including physiologic, in parasternal long axis color Doppler views (PLAX-C). We developed the view classification model using 66,330 frames and evaluated model performance using a hold-out testing dataset with 45 echocardiograms (11,730 frames). We developed the MR detection model using 938 frames and evaluated model performance using a hold-out testing dataset with 42 echocardiograms (182 frames). Metrics to evaluate model performance included accuracy, precision, recall, F1 score (average of precision and recall, 0 to 1 with 1 suggesting perfect precision and recall), and receiver-operating characteristic analysis.
Results
For the PLAX-C view, the view classification CNN achieved an F1 score of 0.97. The MR detection CNN achieved a testing accuracy of 0.86 and an area under the receiver operating characteristic curve of 0.91.
Conclusions
A machine learning model is capable of discerning MR on transthoracic echocardiography. This is an encouraging step toward machine learning-based diagnosis of valvular heart disease on pediatric echocardiograms.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 30 Sep 2022; epub ahead of print
Edwards LA, Feng F, Iqbal M, Fu Y, ... Sable C, Luo J
J Am Soc Echocardiogr: 30 Sep 2022; epub ahead of print | PMID: 36191670
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Abstract

The role of the submitral apparatus in hypertrophic obstructive cardiomyopathy.

Tao J, Duan F, Long J, Meng Q, ... Zhu Z, Wang H
Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease, is characterized by unexplained hypertrophy of any myocardial segment, and has a prevalence of 0.2% to 0.5% among the general population. As one of the phenotypes of HCM, left ventricular outflow tract obstruction (LVOTO) is associated with high morbidity and mortality, including cardiac death. The integration of various factors, including septal hypertrophy, malformation of the mitral valve apparatus, and an anomalous mitral subvalvular apparatus, may contribute to the occurrence of LVOTO. Previous studies have thoroughly discussed the role of the mitral valve in the mechanisms of systolic anterior motion (SAM) and LVOTO. Recent studies have shown the importance of determining the potential mechanism of the submitral apparatus in inducing SAM and LVOTO. We aim to review the recent advances in knowledge regarding the submitral apparatus of HCM patients.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 30 Sep 2022; epub ahead of print
Tao J, Duan F, Long J, Meng Q, ... Zhu Z, Wang H
J Am Soc Echocardiogr: 30 Sep 2022; epub ahead of print | PMID: 36191671
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Abstract

Spatio-temporal complexity of vena contracta and mitral regurgitation grading using 3D echocardiographic analysis.

Lozano-Edo S, Jover-Pastor P, Osa-Saez A, Buendia-Fuentes F, ... Martinez-Dolz L, Aguero J
Background
Spatio-temporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatio-temporal vena contracta complexity and its impact on MR severity grading.
Methods
In 192 patients with suspected moderate or severe MR (100 primary MR, PMR; 92 secondary MR, SMR), we performed 3D vena contracta area (VCA) quantification using single-frame (mid-systolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns, and with cardiac magnetic resonance (CMR) in a subset of cases (n=20).
Results
The vena contracta was non-circular (shape index>1.5) in 90% of patients. Severe non-circularity (shape index > 3) was more prevalent in SMR than in PMR (32.4 vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high with VCAmean (83.3%). PVF systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (AUC 0.88, 0.86 and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as non-severe by CMR more frequently as compared with VCAmid and VCAmean.
Conclusions
Highly prevalent spatio-temporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Oct 2022; epub ahead of print
Lozano-Edo S, Jover-Pastor P, Osa-Saez A, Buendia-Fuentes F, ... Martinez-Dolz L, Aguero J
J Am Soc Echocardiogr: 05 Oct 2022; epub ahead of print | PMID: 36208654
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Abstract

Risk of Mortality with Increasingly Severe Aortic Stenosis: an International Cohort Study.

Strange G, Stewart S, Playford D, Strom JB
Background
Aortic stenosis (AS) is the most common valvular heart disease in high-income countries. Adjusted for clinical confounders, the risk associated with increasing AS severity across the spectrum of AS severity remains uncertain.
Methods
We conducted an international, multicenter, parallel cohort study of 217,599 Australian (76.0 ± 7.3 years, 49.3% women) and 30,865 US (mean age 77.4 ± 7.3 years, 52.2% women) patients aged ≥ 65 years receiving echocardiography. Patients with previous aortic valve replacement were excluded. The risk of increasing AS severity, quantified by peak aortic velocity (Vmax), was assessed through linkage to 97,576 and 14,481 all-cause deaths in Australia and US, respectively.
Results
The distribution of AS severity (mean Vmax 1.7 ± 0.7 m/s) was similar in both cohorts. Compared to those with a Vmax 1.0-1.49 m/s, those with a Vmax 2.50-2.99 m/s (US cohort) or Vmax 3.0-3.49 m/s (Australian cohort) had a 1.5-fold increase in mortality risk within 10 years, adjusting for age, sex, presence of left heart disease and left ventricular ejection fraction. Overall, the adjusted risk of mortality plateaued (1.75 to 2.25-fold increased risk) above a Vmax of 3.5 m/s. This pattern of mortality persisted despite adjustment for a comprehensive list of comorbidities and treatments within the US cohort.
Conclusions
Within large, parallel patient cohorts managed in different health systems, we observed similar patterns of mortality linked to increasingly severe AS. Our findings support ongoing clinical trials of AVR in the non-severe AS population and suggest the need to develop and apply more proactive surveillance strategies in this high-risk population.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Oct 2022; epub ahead of print
Strange G, Stewart S, Playford D, Strom JB
J Am Soc Echocardiogr: 05 Oct 2022; epub ahead of print | PMID: 36208655
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Abstract

Hemodynamic and Echocardiographic Predictors of Mortality in Pediatric Patients on Venoarterial Extracorporeal Membrane Oxygenation - A Multicenter Investigation.

Punn R, Falkensammer CB, Blinder JJ, Fifer CG, ... Roth SJ, Tacy TA
Background
Veno-arterial extracorporeal membrane oxygenation (ECMO) supports patients with advanced cardiac dysfunction; however, mortality occurs in a significant subset of patients. We performed a multicenter, prospective study to determine hemodynamic and echocardiographic (echo) predictors of mortality in children placed on ECMO for cardiac support.
Methods
Over eight years, six heart centers prospectively assessed echo and hemodynamic variables on full and minimum ECMO flow. We enrolled 63 patients ranging in age 1 day - 16 years. Hemodynamic measurements included: heart rate, vasoactive inotropic score, arterio-venous oxygen difference, pulse pressure, and lactate. Echo variables included: shortening/ejection fraction (EF), right ventricular fractional area change, outflow tract Doppler-derived stroke distance (VTI), and degree of atrioventricular valve regurgitation (AVVR). Patients were stratified into those who were able to wean in 48 hours from assessment and survived without a ventricular assist device (VAD) or orthotopic heart transplant (OHT) (successful wean group), and the remaining constituted the unsuccessful wean group. For each patient, we compared the variable from full versus minimum ECMO flow for each group.
Results
Thirty-eight formed the unsuccessful group (2 VAD, 4 OHT, 24 deaths, 60%) and 25 comprised the successful wean group. At minimum flow higher EF (53 +/- 16 vs 40 +/- 20%, p = 0.0094), less mitral regurgitation (MR) (0.8 +/- 0.9 vs 1.4 +/- 0.9, p = 0.0329), and lower central venous pressure (CVP) (12.0 +/- 3.9 vs 14.7 +/- 5.4 mmHg) along with higher VTI (9.0 +/- 2.9 vs 6.8 +/- 3.7 cm, p = 0.0154) correlated with the successful wean group. A longer duration of ECMO (p < 0.0002, 8 vs 5 days) associated with the unsuccessful group. Multivariate logistical regression predicted minimum flow EF and VTI to independently predict successful wean with a cut-off value by ROC analysis of EF >41% and VTI >7.9 cm (AUC = 0.712-0.729, p=0.0005-0.0010).
Conclusion
Diminished VTI or EF during ECMO weaning predicts the need for OHT or VAD support or death in children on ECMO for cardiac dysfunction. Increased post-wean CVP or MR along with a prolonged ECMO course also predicted these adverse outcomes. We propose that these measurements should be utilized to help discriminate who will require alternative methods of circulatory support for survival.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 10 Oct 2022; epub ahead of print
Punn R, Falkensammer CB, Blinder JJ, Fifer CG, ... Roth SJ, Tacy TA
J Am Soc Echocardiogr: 10 Oct 2022; epub ahead of print | PMID: 36228840
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Abstract

Underestimation of Aortic Stenosis Severity by Doppler Mean Gradient During Atrial Fibrillation: Insights from Aortic Valve Weight.

Alkurashi AK, Thaden JJ, Naser JA, El-Am E, ... Maleszewski JJ, Nkomo VT
Background
Doppler mean gradient (MG) can underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) compared to sinus rhythm (SR). Aortic valve weight (AVW) is a flow-independent measure of AS severity. The objective of this study was to determine whether AVW or the AVW:MG ratio were increased in AF versus SR in patients with AS.
Methods
Excised native aortic valves from 495 consecutive patients, median age 77 years (interquartile range [IQR] [71-82]) (40% were female), with LVEF ≥50% who underwent surgical aortic valve replacement for native valve severe AS (aortic valve area ≤1 cm2 or ≤0.6 cm2/m2) were weighed. The excised AVW:MG ratio were compared in AF versus SR in high-gradient AS (HGAS: aortic peak velocity ≥4 m/sec OR MG ≥40 mmHg) and low-gradient AS (LGAS: aortic peak velocity <4 m/sec AND MG <40 mmHg) in sex-specific analyses.
Results
AF was present in 51 patients (10%) (11/51 [22%] had LGAS) and SR in 444 (90%) (23/444 [5%] had LGAS). There was no difference in sex distribution in AF versus SR. Aortic valve area was not different, but forward stroke volume index and transaortic valve flow rate were lower in AF (all p≤0.002); MG was lower in AF versus SR (46 [37-50] vs 50 mmHg [44-61], p<0.0001). Overall AVW was not different (2290 [1830-3063] vs 2140 mg [1530-2958], p=0.31) but overall AVW:MG ratio was higher in AF (55 [41-67] vs 42 [30-55], p=0.001). In sex- and MG-specific analyses, the absolute AVW and the AVW:MG ratio were higher in AF compared to SR in men with HGAS (58 [41-75] vs 51 [39-61], p=0.03), but the differences were not statistically significant in AF versus SR in other groups.
Conclusions
Aortic valve weight was discordant to Doppler MG in AF compared to SR in men with HGAS. Additional studies of the relationship of MG to other measures of AS severity such as leaflet fibrosis are needed.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 10 Oct 2022; epub ahead of print
Alkurashi AK, Thaden JJ, Naser JA, El-Am E, ... Maleszewski JJ, Nkomo VT
J Am Soc Echocardiogr: 10 Oct 2022; epub ahead of print | PMID: 36228839
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Abstract

Association Between Carotid Intraplaque Neovascularization Detected by Contrast-Enhanced Ultrasound and the Progression of Coronary Lesions in Patients Undergoing Percutaneous Coronary Intervention.

Han Y, Ren L, Fei X, Wang J, ... Guo J, Wang Q
Background
It is thought that the progression of the vulnerable plaque is part due to neovascularization and plaque vulnerability is a useful approach for classifying of cardiovascular risk. The retrospective study sought to evaluate the correlation between carotid intraplaque neovascularization (IPN) detected by contrast-enhanced ultrasound (CEUS) and the progression of coronary lesions in patients undergoing percutaneous coronary intervention (PCI).
Methods
CEUS and angiography were performed in the 131 patients undergoing PCI. All patients had angiogram beyond at least 12 months after PCI and that progression was defined by that angiogram. Based on angiographic images, the patients were divided into the progression (PRO) and nonprogression (N-PRO) groups. IPN was graded from 0 to 3 according to each plaque microbubbles appearance and extension detected using CEUS. The plaque with the highest IPN was used for analysis. The logistic regression and receiver operator characteristic analyses were applied to evaluate the risk factors for predicting the progression of coronary lesions in patients undergoing PCI.
Results
In the PRO group, the number of patients with IPN 0, 1, 2, and 3 was 1 (3.3%), 9 (30.0%), 16 (53.3%), and 4 (13.3%), respectively. Significant differences were found in the maximum plaque thickness (MPH) and IPN between groups. IPN and MPH were independent risk contributors of coronary lesions progression in patients undergoing PCI. The sensitivity, specificity, positive predictive value, and negative predictive value of IPN = 1.5 and to predict the progression of coronary lesions were 67%, 91%, 68%, and 89%, respectively. The area under the curve was 0.822.
Conclusions
Carotid plaque neovascularization was correlated with the progression of coronary lesions in patients undergoing PCI. IPN is a clinically useful tool for detecting the progression of coronary lesion risk stratification in patients, especially those > 60 years old.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 25 Oct 2022; epub ahead of print
Han Y, Ren L, Fei X, Wang J, ... Guo J, Wang Q
J Am Soc Echocardiogr: 25 Oct 2022; epub ahead of print | PMID: 36307032
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Abstract

Prevalence and Prognostic Implications of Moderate or Severe Mitral Regurgitation in Patients with Bicuspid Aortic Valve.

Butcher SC, Prevedello F, Fortuni F, Kong WKF, ... Bax JJ, Delgado V
Background
Significant (≥ moderate) mitral regurgitation (MR) could augment the hemodynamic effects of aortic valvular disease in patients with bicuspid aortic valve (BAV), imposing a greater hemodynamic burden on the left ventricle and atrium, possibly culminating in a faster onset of left ventricular (LV) dilation and/or symptoms. The aim of this study was to determine the prevalence and prognostic implications of significant MR in patients with BAV.
Methods
In this large, multicenter, international registry, a total of 2,932 patients (48±18 years, 71% male) with BAV were identified. All patients were evaluated for the presence of significant primary or secondary MR by transthoracic echocardiography and were followed-up for the endpoints of all-cause mortality and event-free survival.
Results
Overall, 147 patients (5.0%) had significant primary (1.5%) or secondary (3.5%) MR. Significant MR was associated with all-cause mortality (HR 2.80, 95% CI 1.91 to 4.11, p<0.001) and reduced event-free survival (HR 1.97, 95% CI 1.58 to 2.46, p<0.001) on univariable analysis. MR was not associated with all-cause mortality (adjusted HR 1.33, 95% CI 0.85 to 2.07, p=0.21) or event-free survival (adjusted HR 1.10, 95% CI 0.85 to 1.42, p=0.49) after multivariable adjustment. However, sensitivity analyses demonstrated that significant MR not due to aortic valve disease retained an independent association with mortality (adjusted HR 1.81, 95% CI 1.04 to 3.15, P=0.037). Subgroup analyses demonstrated an independent association between significant MR and all-cause mortality for individuals with significant aortic regurgitation (HR 2.037, 95% CI 1.025 to 4.049, p=0.042), although this association was not observed for subgroups with significant aortic stenosis or without significant aortic valve dysfunction.
Conclusions
Significant MR is uncommon in patients with BAV. Following adjustment for important confounding variables, significant MR was not associated with adverse prognosis in this large study of patients with BAV, except for the patient subgroup with moderate to severe aortic regurgitation. In addition, significant MR not due to aortic valve disease demonstrated an independent association with all-cause mortality.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 01 Nov 2022; epub ahead of print
Butcher SC, Prevedello F, Fortuni F, Kong WKF, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 01 Nov 2022; epub ahead of print | PMID: 36332801
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Abstract

Left Atrial Reverse Remodeling in Dilated Cardiomyopathy.

Nuzzi V, Raafs A, Manca P, Henkens MTHM, ... Sinagra G, Heymans SRB
Background
Left atrial (LA) dilation is associated with a worse prognosis in several cardiovascular settings but therapies can promote LA reverse remodeling. We aimed to characterize and define the prognostic implications of LA volume (LAVI) reduction in dilated cardiomyopathy (DCM).
Methods
Consecutive DCM patients from two tertiary care centers, with available echocardiography at baseline and at 1-year follow-up, were retrospectively analyzed. LA dilation was defined as LAVI >34 ml/m2, change in LAVI (ΔLAVI) was defined as the 1-year relative LAVI reduction. The outcome was a composite of death/heart transplantation/heart failure hospitalization (D/HTx/HFH).
Results
Five hundred sixty patients were included (age 54±13 years; left ventricular ejection fraction (LVEF) 31±10%, LAVI 45±18 ml/m2). Baseline LAVI had a non-linear association with the risk of D/HTx/HFH, independently from age, LVEF, MR and medical therapy (p<0.01). At 1-year follow-up, LAVI decreased in 374 patients (67%, median ΔLAVI -24%, interquartile range -37% - -11%). Factors independently associated with ΔLAVI were higher baseline LAVI and lower baseline LVEF. After multivariable adjustment, ΔLAVI showed a linear association with the risk of D/HTx/HFH (HR 0.96, 95% 0.93-0.99 per 5% decrease, p=0.042). At 1-year follow-up, patients with a reduction in LAVI greater than 10% and LAVI normalization (i.e. follow-up LAVI ≤34ml/m2) (31% of the overall cohort) were at lower risk of D/HTx/HFH (HR 0.37, 95% C.I. 0.35-0.97, p=0.028).
Conclusions
In a large cohort of DCM, 1-year reduction in LAVI is observed in a number of patients. The association between reduction in LAVI and D/HTx/HFH suggests that LA structural reverse remodeling might be considered an additional parameter useful in the individualized risk stratification of patients with DCM.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 01 Nov 2022; epub ahead of print
Nuzzi V, Raafs A, Manca P, Henkens MTHM, ... Sinagra G, Heymans SRB
J Am Soc Echocardiogr: 01 Nov 2022; epub ahead of print | PMID: 36332803
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Abstract

Association of Echocardiographic Parameter E/e\' with Cardiovascular Events in A Diverse Population of Inpatients and Outpatients with and without Cardiac Diseases and Risk Factors.

Wu VC, Huang YC, Wang CL, Huang YC, ... Huang YT, Chang SH
Background
The echocardiographic parameter E/e\' has been associated with cardiovascular (CV) events. However, few studies have analyzed multiple associated CV outcomes using E/e\' in a diverse population of both inpatients and outpatients with and without cardiac diseases and risk factors.
Methods
Medical records of 75,393 patients without atrial fibrillation (AF) with first available E/e\' were retrieved from our hospital database. Patients with mitral valve disease were excluded and the remainder were studied in Protocol 1 (70,819 patients). Patients with hypertension, diabetes mellitus, hyperlipidemia, CV diseases, prior CV events, CV surgeries, and left ventricular ejection fraction (LVEF) <50% or missing LVEF were further excluded and the remaining patients were studied in Protocol 2 (14,665 patients). The study outcomes are major adverse cardiovascular events (MACE), which included myocardial infarction (MI), atrial fibrillation (AF), ischemic and hemorrhagic stroke (IHS), hospitalization for heart failure (HHF) and cardiac death. The primary outcome were MACE and each of the MACE components.
Results
At the end of maximal 5-year follow-up (median 22.18 months with interquartile range [IQR] 7.20-49.08 months for MACE in Protocol 1, and 23.46 months with IQR 8.15-49.02 months for MACE in Protocol 2), compared with an E/e\' value of <8, an intermediate value of E/e\' 8-15 and a high value of E/e\' >15 were significantly associated with MACE, MI, AF, IHS, HHF, and cardiac death in Protocol 1 (all p <.0001). In Protocol 2, an intermediate E/e\' value of 8-15 and a high value of E/e\' value >15 were significantly associated with MACE, MI, AF, IHS, HHF, and CV death (all p <.05), except an intermediate value E/e\' 8-15 was not associated with AF.
Conclusions
In a diverse population of inpatients and outpatients with and without cardiac diseases and risk factors, the echocardiographic parameter E/e\' was associated with cardiovascular events and a useful a marker of risk.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 01 Nov 2022; epub ahead of print
Wu VC, Huang YC, Wang CL, Huang YC, ... Huang YT, Chang SH
J Am Soc Echocardiogr: 01 Nov 2022; epub ahead of print | PMID: 36332804
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Abstract

Application of a Novel 2D Echocardiographic Calcium Quantification Method to Assess All Severities of Aortic Stenosis.

Desai K, Slostad B, Twing A, Krishna H, Frazin L, Kansal M
Background
Aortic valve calcification (AVC) is a strong predictor of aortic stenosis (AS) severity. The two-dimensional AVC (2D-AVC) ratio, a gain-independent ratio comprised of the average pixel density of the aortic valve and the aortic annulus, has previously shown strong correlations with 2D echocardiographic hemodynamic parameters for severe aortic stenosis and aortic valve calcification by cardiac computed tomography. We hypothesize that the 2D-AVC ratio correlates with hemodynamic parameters in all severities of AS.
Methods
A total of 285 patients with a normal aortic valve (AV) (n = 49), aortic sclerosis (n = 75), or mild (n = 38), moderate (n = 72), or severe (n = 51) AS undergoing 2D echocardiography were retrospectively evaluated and the 2D-AVC ratios were correlated to mean AV gradient (AV MnG), peak AV velocity (AV Vmax), AV area (AVA) and dimensionless index (DI). The 2D-AVC ratios of various AS severities were compared against each other via area under the curve (AUC) analysis.
Results
2D-AVC ratio strongly correlated with AV MnG (r = 0.79, p < 0.0001) and AV Vmax (r = 0.78, p < 0.0001). There was moderate correlation with the AVA (r = -0.58, p < 0.0001) and DI (r = -0.67, p < 0.0001) across all AS severities. 2D-AVC ratio also distinguished non-moderate AS (mild AS + normal AV) from moderate or greater (moderate + severe) AS (AUC = 0.93), and moderate vs severe AS (AUC = 0.88).
Conclusion
2D-AVC ratio exhibits moderate to strong correlation with 2D echocardiographic hemodynamic parameters across all severities of AS.
Clinical implications
2D-AVC ratio is a novel flow-independent echocardiographic method that exhibits moderate to strong correlation with traditional echocardiographic 2D parameters of AS severity. The ratio may be an additional tool to further adjudicate AS severity with the potential for clinical utility in discriminating moderate versus severe AS.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Nov 2022; epub ahead of print
Desai K, Slostad B, Twing A, Krishna H, Frazin L, Kansal M
J Am Soc Echocardiogr: 05 Nov 2022; epub ahead of print | PMID: 36347388
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Abstract

Left atrial structural and functional response in kidney transplant recipients treated with mesenchymal stromal cell therapy and early tacrolimus withdrawal.

Meucci MC, Reinders MEJ, Groeneweg KE, Bezstarosti S, ... De Fijter JW, Delgado V
Background
Autologous bone marrow derived mesenchymal stromal cell (MSC) therapy and withdrawal of calcineurin inhibitors (CNIs) in kidney transplant patients has shown to improve systemic blood pressure control and left ventricular hypertrophy regression. In the current sub-analysis, we aimed to evaluate the impact of this novel immunosuppressive regimen on the longitudinal changes of LA structure and function after kidney transplantation.
Methods
Kidney transplant recipients randomized to MSC therapy - infused at week 6 and 7 after transplantation, with complete discontinuation at week 8 of tacrolimus (MSC group) - or standard tacrolimus dose (control group) were evaluated with transthoracic echocardiography at week 4 and 24 after kidney transplantation. The changes in echocardiographic parameters were compared between the randomization arms using an analysis of covariance model, adjusted for baseline variable.
Results
54 participants (MSC therapy =27; tacromilus therapy =27) were included. There was no significant interaction between the allocated treatment and the changes of indexed maximal LA volume (LAVImax) over the time. Conversely, between 4 and 24 weeks post-transplantation, an increase in indexed minimal LA volume (LAVImin) was observed in control subjects, while it remained unchanged in the MSC group, leading to a significant difference between groups (p=0.021). Additionally, patients treated with MSC therapy showed a benefit in LA function, assessed by a significant interaction between changes in LA emptying fraction (LAEF) and LA reservoir strain and the randomization arm (p=0.012 and p=0.027, respectively).
Conclusion
The combination of MSC therapy and CNIs withdrawal prevents progressive LA dilation and dysfunction in the first 6 months after kidney transplantation. LAVmin and LA reservoir strain may be more sensitive markers of LA reverse remodelling, as compared to LAVmax.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Nov 2022; epub ahead of print
Meucci MC, Reinders MEJ, Groeneweg KE, Bezstarosti S, ... De Fijter JW, Delgado V
J Am Soc Echocardiogr: 05 Nov 2022; epub ahead of print | PMID: 36347387
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Abstract

Recognized and Unrecognized Value of Echocardiography in Guideline and Consensus Documents Regarding Patients with Chest Pain.

Sorrell VL, Lindner JR, Pellikka PA, Kirkpatrick JN, Muraru D
Guideline and consensus documents have recently been published on the important topic of the noninvasive evaluation of patients presenting with chest pain or patients with known acute or chronic coronary syndromes1,2. Authors for these documents have included members representing multispecialty imaging societies. Yet, the process of generating consensus and the need to produce concise written documents have led to a situation where the particular advantages of echocardiography are overlooked. Broad guidelines such as these can be helpful when it comes to \"when to do\" noninvasive cardiac testing, but they do not pretend to offer nuances on \"how to do\" noninvasive cardiac testing. This report details the particular value of echocardiography and potential explanations for its understated role in recent guidelines. This report is categorized into the following sections: (1) impact of the level of evidence (LOE) in guideline creation; (2) versatility of echocardiography in the assessment of chest pain (CP) and the inimitable role for echo Doppler echocardiography in the assessment of dyspnea; (3) value of point-of-care ultrasound (POCUS) in assessing CP and dyspnea; and (4) the future role of echocardiography in ischemic heart disease.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 11 Nov 2022; epub ahead of print
Sorrell VL, Lindner JR, Pellikka PA, Kirkpatrick JN, Muraru D
J Am Soc Echocardiogr: 11 Nov 2022; epub ahead of print | PMID: 36375734
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Abstract

Pediatric Normal Values and Z-Score Equations for Left and Right Ventricular Strain by Two-Dimensional Speckle-Tracking Echocardiography Derived from a Large Cohort of Healthy Children.

Romanowicz J, Ferraro AM, Harrington JK, Sleeper LA, ... Powell AJ, Harrild DM
Background
Strain values vary with age in children and are both vendor- and platform-specific. Philips QLab 10.8 and Tomtec AutoStrain are two widely-utilized strain analysis platforms, and both incorporate recent EACVI-ASE-Industry Strain Standardization Task Force guidelines. We sought to establish normal strain values and Z-scores for both platforms using a large dataset of healthy children and to compare values among these two platforms and a previous version-QLab 10.5-which predated the Task Force guidelines.
Methods
Echocardiograms from 1,032 subjects <21 years old with structurally and functionally normal hearts were included. Images were obtained on the Philips EPIQ platform. Left ventricular (LV) and right ventricular (RV) strain were analyzed using QLab 10.8 and AutoStrain and measurement reliability was assessed. Z-score equations were derived as a function of age for QLab 10.8 (LV longitudinal and circumferential strain) and AutoStrain (LV and RV longitudinal strain). A subset (n=309) was analyzed by QLab 10.5. Strain values were compared among the three platforms.
Results
For both of the newer platforms, strain varied with age, with magnitude reaching a maximum at 4-5 years. For LV longitudinal strain, the largest differences in value were observed in the youngest patients when using QLab 10.5; the other two platforms were similar. LV circumferential strain measurements (QLab 10.5 vs 10.8) were different for all ages, as were measurements of RV longitudinal strain (QLab 10.8 vs AutoStrain). Reliability was greater for AutoStrain than for QLab 10.8, and greater for LV than for RV strain.
Conclusions
We generated normal RV and LV strain values and Z-scores from a large cohort of children for two commonly-utilized platforms in pediatric echocardiography laboratories. Following incorporation of Task Force guidelines, the greatest improvement in standardization was seen in infants. Small differences persist between modern platforms; however, these results support the cautious consideration of comparing inter-platform measurements.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 19 Nov 2022; epub ahead of print
Romanowicz J, Ferraro AM, Harrington JK, Sleeper LA, ... Powell AJ, Harrild DM
J Am Soc Echocardiogr: 19 Nov 2022; epub ahead of print | PMID: 36414123
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Abstract

Prognostic Value of Left Atrial Strain in Aortic Stenosis: A Competing Risk Analysis.

Tan ESJ, Jin X, Oon YY, Chan SP, ... Richards AM, Ling LH
Background
The role of left atrial (LA) strain as an imaging biomarker in aortic stenosis is not well established. The aim of this study was to investigate the prognostic performance of phasic LA strain in relation to clinical and echocardiographic variables and N-terminal pro-B-type natriuretic peptide in asymptomatic and minimally symptomatic patients with moderate to severe aortic stenosis and left ventricular ejection fraction > 50%.
Methods
LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured using speckle-tracking echocardiography. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, progression to New York Heart Association functional class III or IV, acute coronary syndrome, or syncope. Secondary outcomes 1 and 2 comprised the same end points but excluded acute coronary syndrome and additionally syncope, respectively. The prognostic performance of phasic LA strain cutoffs was evaluated in competing risk analyses, aortic valve replacement being the competing risk.
Results
Among 173 patients (mean age, 69 ± 11 years; mean peak transaortic velocity, 4.0 ± 0.8 m/sec), median LASr, LAScd, and LASct were 27% (interquartile range [IQR], 22%-32%), 12% (IQR, 8%-15%), and 16% (IQR, 13%-18%), respectively. Over a median of 2.7 years (IQR, 1.4-4.6 years), the primary outcome and secondary outcomes 1 and 2 occurred in 66 (38%), 62 (36%), and 59 (34%) patients, respectively. LASr < 20%, LAScd < 6%, and LASct < 12% were identified as optimal cutoffs of the primary outcome. In competing risk analyses, progressing from echocardiographic to echocardiographic-clinical and combined models incorporating N-terminal pro-B-type natriuretic peptide, LA strain parameters outperformed other key echocardiographic variables and significantly predicted clinical outcomes. LASr < 20% was associated with the primary outcome and secondary outcome 1, LAScd < 6% with all clinical outcomes, and LASct < 12% with secondary outcome 2. LAScd < 6% had the highest specificity (95%) and positive predictive value (82%) for the primary outcome, and competing risk models incorporating LAScd < 6% had the best discriminative value.
Conclusions
In well-compensated patients with moderate to severe aortic stenosis and preserved left ventricular ejection fractions, LA strain was superior to other echocardiographic indices and incremental to N-terminal pro-B-type natriuretic peptide for risk stratification. LAScd < 6%, LASr < 20%, and LASct < 12% identified patients at higher risk for adverse outcomes.

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

J Am Soc Echocardiogr: 22 Nov 2022; epub ahead of print
Tan ESJ, Jin X, Oon YY, Chan SP, ... Richards AM, Ling LH
J Am Soc Echocardiogr: 22 Nov 2022; epub ahead of print | PMID: 36441088
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Abstract

Correlation Between Echocardiographic Diastolic Parameters and Invasive Measurements of Left Ventricular Filling Pressure in Patients with Takotsubo Cardiomyopathy.

Dayco JS, Kherallah RY, Epstein J, Adegbala O, ... Oviedo C, Afonso L
Background
The extent of diastolic dysfunction is of clinical importance in the risk stratification and management of Takotsubo cardiomyopathy (TC) patients. Standard echocardiographic indices for diastolic dysfunction have robust predictive ability in other diseases, however, these have not been validated in TC. This study compares Doppler metrics of diastolic function against catheterization measured filling pressures in TC.
Methods
Patients with TC who met our inclusion and exclusion criteria were evaluated with echocardiography and catheterization obtained within 24 hours. Both LVEDP (Left Ventricular End Diastolic Pressure) and LV Pre-A diastolic pressures were obtained from catheterization tracings. The echocardiographic parameters for diastolic function were extracted using the American Society of Echocardiography (ASE) recommendations and a previously validated regression equation for mean left atrial pressure (mLAP).
Results
A total of 51 patients with TC were included. Patient were predominantly females (72.5%), with mean age 58 ± 13, and mean ejection fraction 24 ± 10%. The E/e\' (septal, average, and lateral), and calculated mean LAP correlated positively with catheterization LV pre-A, with fair to moderate correlation (coefficients range: 0.38 to 0.44). The t-test mean difference between the LV pre-A pressure and calculated mLAP was 0.77 ± 7.34 mmHg (95% CI ± 14.68 mmHg) suggesting inconsistent measures. The mLAP also exhibited poor diagnostic ability to discriminate elevated LV pre-A diastolic pressure with a ROC area under the curve of 0.69 (95% CI 0.50 - 0.88).
Conclusions
Commonly used echocardiographic parameters for diastolic function demonstrated less than optimal correlation, with poor sensitivity and specificity, when compared to invasively measured LVEDP or LV-pre-A wave diastolic pressures in TC. Precise characterization of LV filling pressure in TC using contemporary noninvasive echocardiographic parameters appears challenging. Invasive measurements of filling pressure should remain the gold standard for optimal risk stratification and management of TC.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 25 Nov 2022; epub ahead of print
Dayco JS, Kherallah RY, Epstein J, Adegbala O, ... Oviedo C, Afonso L
J Am Soc Echocardiogr: 25 Nov 2022; epub ahead of print | PMID: 36442765
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Abstract

\"Association of Bulboventricular foramen size and need for early intervention in infants with tricuspid atresia or double inlet left ventricle with normally related great arteries\".

Skaff AM, Parra DA, Soslow JH, Shuplock JM
Introduction
The association of bulboventricular foramen (BVF) size and systemic outflow adequacy has been studied in patients with tricuspid atresia (TA) or double inlet left ventricle (DILV) with transposed great arteries (TGA). We aimed to determine the relationship between the initial BVF size and risk for progressive pulmonary outflow obstruction requiring intervention to increase pulmonary blood flow in patients with TA or DILV with normally related great arteries.
Methods
Patients with TA or DILV with normally related great arteries were identified by retrospective chart review at a single center from 2005 to 2021. Patients were stratified by indexed BVF area (iBVFA) to determine the relationship of iBVFA size and the need for intervention prior to the Glenn operation to establish supplemental pulmonary blood flow with either a Blalock-Taussig-Thomas shunt (BTTS) or patent ductus arteriosus (PDA) stent. Patients were followed through the time of their Glenn operation. Logistic regression analysis was performed to determine optimal iBVFA cut-points.
Results
Thirty-seven patients with TA or DILV with normally related great arteries were included. Sixteen had an iBVFA <1 cm2/m2 with all 16 (100%) requiring either a BTTS or PDA stent to increase pulmonary blood flow prior to the Glenn operation. Seventeen had an iBVFA of 1-2 cm2/m2 with 10 (59%) requiring either a BTTS or PDA stent. Nine of those 10 demonstrated flow acceleration across the BVF and/or pulmonary outflow tract. Four had an iBVFA >2 cm2/m2 with only 1 patient (25%) requiring a BTTS. Among our cohort, an iBVFA less than 1.8 cm2/m2 provided a sensitivity of 96% with good positive and negative predictive values (81% and 80% respectively) for requiring intervention with a BTTS or PDA stent prior to the Glenn operation.
Conclusions
An iBVFA of 1.8 cm2/m2 or less on the initial postnatal echocardiogram is associated with the development of subpulmonary obstruction requiring intervention with a BTTS or PDA stent prior to the Glenn operation, with the highest risk noted in those with an iBVFA of 1 cm2/m2 or less. Factors such as BVF flow acceleration or pulmonary outflow tract narrowing should also be considered in the decision to augment pulmonary blood flow.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 25 Nov 2022; epub ahead of print
Skaff AM, Parra DA, Soslow JH, Shuplock JM
J Am Soc Echocardiogr: 25 Nov 2022; epub ahead of print | PMID: 36442767
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Abstract

Recommendations for the Use of Echocardiography in the Evaluation of Rheumatic Heart Disease: A Report from the American Society of Echocardiography.

Pandian NG, Kim JK, Arias Godinez JA, Marx GR, ... Campos Vieira ML, Little SH
Acute rheumatic fever and its chronic sequela, rheumatic heart disease (RHD), pose major health problems globally, and remain the most common cardiovascular disease in children and young people worldwide. Echocardiography is the most important diagnostic tool in recognizing this preventable and treatable disease and plays an invaluable role in detecting the presence of subclinical disease needing prompt therapy or follow-up assessment. This document provides recommendations for the comprehensive use of echocardiography in the diagnosis and therapeutic intervention of RHD. Echocardiographic diagnosis of RHD is made when typical findings of valvular and subvalvular abnormalities are seen, including commissural fusion, leaflet thickening, and restricted leaflet mobility, with varying degrees of calcification. The mitral valve is predominantly affected, most often leading to mitral stenosis. Mixed valve disease and associated cardiopulmonary pathology are common. The severity of valvular lesions and hemodynamic effects on the cardiac chambers and pulmonary artery pressures should be rigorously examined. It is essential to take advantage of all available modalities of echocardiography to obtain accurate anatomic and hemodynamic details of the affected valve lesion(s) for diagnostic and strategic pre-treatment planning. Intraprocedural echocardiographic guidance is critical during catheter-based or surgical treatment of RHD, as is echocardiographic surveillance for post-intervention complications or disease progression. The role of echocardiography is indispensable in the entire spectrum of RHD management.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 22 Nov 2022; epub ahead of print
Pandian NG, Kim JK, Arias Godinez JA, Marx GR, ... Campos Vieira ML, Little SH
J Am Soc Echocardiogr: 22 Nov 2022; epub ahead of print | PMID: 36428195
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Abstract

Prognostic Impact of Indeterminate Diastolic Function in Patients with Functionally Insignificant Coronary Stenosis.

Chung YJ, Choi KH, Lee SH, Shin D, ... Gwon HC, Lee JM
Background
Cardiac diastolic dysfunction is an independent predictor of mortality, regardless of LV systolic function. However, the current guidelines that define cardiac diastolic dysfunction may underrate the clinical implications of those with indeterminate diastolic function.
Objectives
We sought to evaluate the prognostic implications of indeterminate diastolic function on echocardiography and its association with coronary microvascular dysfunction (CMD).
Methods
A total of 330 patients without LV systolic dysfunction and significant epicardial coronary stenosis (fractional flow reserve>0.80) were analyzed from a prospective registry. Cardiac diastolic dysfunction was defined according to two algorithms depending on the presence of myocardial disease. First, the presence of myocardial disease and evidence of elevated LV filling pressure indicated diastolic dysfunction. Second, diastolic function in those without myocardial disease was defined using echocardiographic parameters (E/e\', e\' velocity, tricuspid regurgitation velocity, and left atrial volume index). Patients who did not meet half of the available criteria were classified as having indeterminate diastolic function. CMD was defined as coronary flow reserve<2.0 and index of microcirculatory resistance≥25U. The primary outcome was cardiovascular death or admission for heart failure at 5 years.
Results
Coronary flow reserve was lower in patients with indeterminate diastolic function compared with those with no diastolic dysfunction (3.5±1.6 vs. 3.2±1.6, P=0.002). The prevalence of CMD was also higher in patients with indeterminate diastolic function than those with no diastolic dysfunction (10.6% vs. 4.9%, P<0.034). Patients with indeterminate diastolic function showed significantly higher risk of cardiovascular death or admission for heart failure than those without, but not greater than those with definite diastolic dysfunction (cumulative incidence: 12.6%, 27.2%, and 32.7%, respectively, log-rank P<0.001). Presence of CMD and elevated LV filling pressure (E/e\'>14) were independent predictors for cardiovascular death or admission for heart failure in patients with indeterminate diastolic function.
Conclusion
Patients with indeterminate diastolic function on echocardiogram showed higher risk of cardiovascular death or admission for heart failure than those with no diastolic dysfunction. Presence of CMD and elevated LV filling pressure were independent predictors for cardiovascular death or admission for heart failure among patients with indeterminate diastolic function.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 02 Dec 2022; epub ahead of print
Chung YJ, Choi KH, Lee SH, Shin D, ... Gwon HC, Lee JM
J Am Soc Echocardiogr: 02 Dec 2022; epub ahead of print | PMID: 36470507
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Abstract

Metoprolol Improves Left Ventricular Longitudinal Strain at Rest and during Exercise in Obstructive Hypertrophic Cardiomyopathy.

Dybro AM, Rasmussen TB, Nielsen RR, Pedersen ALD, ... Jensen MK, Poulsen SH
Background
Patients with obstructive hypertrophic cardiomyopathy (HCM) often experience symptoms of heart failure upon exertion despite having normal left ventricular (LV) ejection fractions. Longitudinal strain (LS) may be a more sensitive marker of systolic dysfunction in patients with LV hypertrophy. The aims of this study were to characterize LV segmental LS and global LS (GLS) at rest and during exercise and to assess if first-line treatment with β-blockers improves LV systolic performance.
Methods
Twenty-nine patients with obstructive HCM and New York Heart Association functional class ≥ II symptoms were enrolled in a double-blind, placebo-controlled, randomized crossover trial. Patients received metoprolol 150 mg or placebo for two consecutive 2-week periods in random order. Echocardiographic assessment with speckle-tracking-derived LS was performed at rest and during peak exercise at the end of each treatment period.
Results
During placebo treatment, resting values of segmental LS showed an apical-basal difference of -10.3% (95% CI, -12.7% to -7.8%; P < .0001), with a severely abnormal value of the basal segment of -9.3 ± 4.2%. Treatment with metoprolol was associated with more negative LS values of the apical segment (-2.8%; 95% CI, -4.2% to -1.3%; P < .001) and the mid segment (-1.1%; 95% CI, -2.0% to -0.3%; P = .007). During peak exercise there was a deterioration in LV GLS, but treatment with metoprolol was associated with more negative peak exercise LV GLS (-1.3 %; 95% CI, -2.6% to -0.1%; P = .03).
Conclusions
Systolic performance assessed by LV GLS showed impaired values at rest and during exercise, with severely depressed values of the basal and mid segments. Treatment with metoprolol improved LV GLS upon exercise, indicating a beneficial effect of β-blocker treatment on LV systolic function.

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

J Am Soc Echocardiogr: 19 Sep 2022; epub ahead of print
Dybro AM, Rasmussen TB, Nielsen RR, Pedersen ALD, ... Jensen MK, Poulsen SH
J Am Soc Echocardiogr: 19 Sep 2022; epub ahead of print | PMID: 36444740
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Impact:

This program is still in alpha version.