<div><h4>Artificial Intelligence Assisted Left Ventricular Diastolic Function Assessment and Grading：Multi-view versus Single-view.</h4><i>Chen X, Yang F, Zhang P, Lin X, ... Burkhoff D, He K</i><br /><b>Background</b><br />Clinical assessment and grading of left ventricular diastolic function (LVDF) requires quantification of multiple echocardiographic parameters interpreted according to established guidelines which depends on experienced clinicians and is time-consuming. We aim to develop an artificial intelligence (AI) assisted system to facilitate the clinical assessment of LVDF.<br /><b>Methods</b><br />We used 1304 studies (33404 images) to develop a view classification model to select 6 specific views required for LVDF assessment. We used 2238 studies (16794 2D images and 2198 Doppler images) to develop 2D and Doppler segmentation models respectively to quantify key metrics of diastolic function. We used 2150 studies with definite LVDF labels determined by 2 experts to train single-view-based classification models by AI interpretation of strain metrics or video. The accuracy and efficiency of these models were tested in an external dataset of 388 prospective studies.<br /><b>Results</b><br />The view classification model identified views required for LVDF assessment with a good sensitivity (>0.9) and view segmentation models successfully outlined key regions of these views with Inter Over Union (IoU) >0.8 in internal validation dataset. In external test dataset of 388 cases, AI quantification of 2D and Doppler showed narrow limits of agreement (LOA) compared with the two experts (e.g., LVEF: -12.02% to 9.17%; E/e\': -3.04 to 2.67). These metrics were used to detect LV diastolic dysfunction (DD) and grade DD with a accuracy of 0.9 and 0.92 respectively. Concerning single-view-based method, the overall accuracy of DD detection was 0.83 and 0.75 by strain-based and video-based model; and the accuracy of DD grading was 0.85 and 0.8 respectively. These models could achieve the diagnosis and grading of LVDD in a few seconds, greatly saving time and labor.<br /><b>Conclusions</b><br />AI models successfully achieved LVDF assessment and grading that compared favorably to human experts reading according to guideline-based algorithms. Moreover, under conditions when Doppler variables were missing, AI models could provide assessment by interpreting 2D strain metrics or videos from a single view. These models had potential to save labor, cost and facilitate workflow of clinical LVDF assessment.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 10 Jul 2023; epub ahead of print</small></div>

<div><h4>Echocardiography assessment of Left Ventricular Function in Extremely Preterm Infants, Born less than 28 weeks Gestation, with Bronchopulmonary Dysplasia and Systemic Hypertension.</h4><i>Reyes-Hernandez ME, Bischoff AR, Giesinger RE, Rios DR, Stanford AH, McNamara PJ</i><br /><b>Background</b><br />The survival of smaller and more immature premature infants has been associated with life-long cardiorespiratory comorbidities. Infants with bronchopulmonary dysplasia (BPD) undergo routine screening echocardiography to evaluate for development of chronic pulmonary hypertension, a late manifestation of pulmonary vascular disease (PVD).<br /><b>Methods</b><br />Our aim was to evaluate left ventricular (LV) performance in infants with BPD and PVD, who developed systemic hypertension. We hypothesized that infants with hypertension were more likely to have impaired LV performance. We present a single center cross-sectional study of premature infants born less than 28 0/7 weeks GA with a clinical diagnosis of BPD. Infants were categorized by the systolic arterial pressure (SAP) at time of echocardiography as Hypertensive (SAP ≥90mmHg) or Normotensive (SAP <90mmHg). 64 patients were included.<br /><b>Results</b><br />Infants with hypertension showed altered LV diastolic function with prolonged TDI-derived IVRT (54.2±5.1 vs. 42.9±8.2, p<0.001), lower E:A ratio and higher E:e\'. Indices of left heart volume/pressure loading [LA:Ao and LV end-diastolic volume (6.1±2 vs. 4.2±1.2 p<0.001)] were also higher in the HT group. Finally, infants in the hypertensive group had higher pulmonary vascular resistance index (PVRi) (4.42±1.1 vs. 3.69±0.8 p=0.004).<br /><b>Conclusions</b><br />We conclude that extremely preterm infants with BPD, who develop systemic hypertension are at risk of abnormal LV diastolic dysfunction. Increased PVRi in the hypertensive group may relate to pulmonary venous hypertension secondary to LV dysfunction. This is an important consideration in this cohort, when selecting the physiologically most appropriate treatment.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 22 Aug 2023; epub ahead of print</small></div>

<div><h4>Myocardial Work in Apical Hypertrophic Cardiomyopathy.</h4><i>Peters M, Jan MF, Ashraf M, Sanders H, ... Khandheria B, Tajik AJ</i><br /><b>Background</b><br />Pressure-strain loop analysis is a novel echocardiographic technique to calculate myocardial work indices that has not been applied to patients with apical hypertrophic cardiomyopathy (ApHCM). We hypothesized that myocardial work indices differ between patients with ApHCM and those with non-apical HCM (non-ApHCM). This study aimed to (1) evaluate myocardial work indices in patients with ApHCM compared to those with non-ApHCM, (2) describe associations with relevant clinical variables, and (3) examine associations with significant late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR).<br /><b>Methods</b><br />We retrospectively identified 48 patients with ApHCM and 69 with non-ApHCM who had measurements of global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). We evaluated available CMR data on 34 patients with ApHCM and 51 with non-ApHCM. Multivariable regression models correcting for traditional cardiac risk factors were used to evaluate the associations of myocardial work indices with relevant clinical variables.<br /><b>Results</b><br />Median GLS (-11% vs -18%, p < .001), GWI (966 mmHg% vs 1803 mmHg%, p < .001), and GCW (1050 mmHg% vs 1988 mmHg%, p < .001) were significantly impaired in patients with ApHCM compared to those with non-ApHCM. Increasing NT-ProBNP, abnormal ultra-sensitive troponin, and increasing maximal LV wall thickness were significantly associated with reduced GWI and GCW in patients with ApHCM (p < .05). GCW had only modest accuracy (AUC 0.70) to predict LGE in patients with ApHCM. However, in patients with non-ApHCM, GLS was the strongest predictor of LGE (AUC 0.91), with a -17% cutoff yielding 81% sensitivity and 80% specificity.<br /><b>Conclusions</b><br />Myocardial work indices are significantly impaired in patients with ApHCM compared to those with non-ApHCM and correlate with important clinical variables. GLS, GWI, and GCW are more strongly predictive of fibrosis in patients with non-ApHCM than ApHCM.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>Preservation of Circumferential and Radial Left Ventricular Function as a Mitigating Mechanism for Impaired Longitudinal Strain in Early Cardiac Amyloidosis.</h4><i>Slivnick JA, Singulane C, Sun D, Eshun D, ... Mor-Avi V, Lang RM</i><br /><b>Background</b><br />In patients with cardiac amyloidosis (CA), left ventricular ejection fraction (LVEF) is frequently preserved, despite commonly reduced global longitudinal strain (GLS). We hypothesized that non-longitudinal contraction may initially serve as a mitigating mechanism to maintain cardiac output, and studied the relationship between global circumferential (GCS) and radial (GRS) strain with LVEF and extracellular volume (ECV), a marker of amyloid burden.<br /><b>Methods</b><br />CA patients who underwent cardiac magnetic resonance (CMR) (n=140, 70.7±11.5 years, 66% male) or echocardiography (n=67, 71±13 years, 66% male), and normal controls (CMR: n=20; echocardiography: n=45) were retrospectively identified. GCS, GLS, and GRS were quantified using feature-tracking CMR or speckle-tracking echocardiography, and compared between CA patients with preserved and reduced LVEF (CA<sub>HFpEF</sub>, CA<sub>HFrEF</sub>) and controls. The prevalence of impaired strain (magnitudes <2.5th percentiles of the controls) was compared between CA<sub>HFpEF</sub> and CA<sub>HFrEF</sub>, and between ECV quartiles.<br /><b>Results</b><br />While echocardiography-derived GLS was impaired in both CA<sub>HFpEF</sub> (-13.4±3.1%, p<0.003) and CA<sub>HFrEF</sub> (-9.1±3.2%, p<0.003), compared to controls (-20.8±2.4%), GCS was more impaired in CA<sub>HFrEF</sub> compared to both controls (-15.6±5.0% vs -32.3±3.3%, p<0.003) and CA<sub>HFpEF</sub> (-30.4±5.7%, p<0.003), and did not differ between CA<sub>HFpEF</sub> and controls (p=0.24). The prevalence of abnormal CMR-derived GCS (p<0.0001) and GRS (p<0.0001) but not GLS (p=0.054) varied significantly across ECV quartiles.<br /><b>Conclusions</b><br />Among CA patients with preserved LVEF, preserved GCS and GRS despite near-universally impaired GLS may be explained by an initial predominantly subendocardial involvement, where mostly longitudinal fibers are located. If confirmed in future studies, these findings may facilitate identification of patients with early stages of CA, when treatments may be most effective.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 11 Aug 2023; epub ahead of print</small></div>

<div><h4>State-of-the-Art: Non-Invasive Assessment of Left Ventricular Function through Myocardial Work.</h4><i>Moya A, Buytaert D, Penicka M, Bartunek J, Vanderheyden M</i><br /><AbstractText>The assessment of myocardial work(MW) using non-invasive pressure-strain loop analysis is a novel echocardiographic method that provides a more precise assessment of the cardiac performance, considering the left ventricular loading condition. By integrating various MW components such as index, efficiency, constructive and wasted work an extensive analysis of left ventricular mechanics and energetics can be achieved. This approach offers a more comprehensive assessment of global cardiac function and performance, surpassing conventional surrogate indices. In this review, we aim to summarize the existing knowledge on MW and its distinctive characteristics in various cardiac pathologies.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 10 Jul 2023; epub ahead of print</small></div>

<div><h4>Echocardiographic Versus Invasive Aortic Valve Gradients In Different Clinical Scenarios.</h4><i>Abbas AE, Khalili H, Madanat L, Elmariah S, ... Michael Mack , Pibarot P</i><br /><b>Background</b><br />The role of echocardiography in deriving transvalvular mean-gradients from transaortic velocities in aortic stenosis (AS) and in degenerated surgical bioprosthetic valves (SVD) is well established. However, reports following surgical aortic valve replacement (SAVR), post-transcatheter aortic valve replacement (TAVR), and valve-in-valve-TAVR (ViV-TAVR) have cautioned against the use of echocardiography-derived mean-gradients to assess normal functioning bioprosthesis due to discrepancy compared to invasive measures in a phenomenon called discordance.<br /><b>Methods</b><br />In a multicenter study, intra-procedural echocardiographic and invasive mean-gradients in AS, SVD, post-native-TAVR, and post-ViV-TAVR were compared, when obtained concomitantly, and discharge echocardiographic gradients were recorded. Absolute discordance (intra-procedural echocardiographic - invasive mean-gradient) and percent discordance (intra-procedural echocardiographic - invasive mean-gradient/echocardiographic mean-gradient) were calculated. Multivariable regression analysis to determine variables independently associated with elevated post-procedure invasive gradients ≥20mmHg, absolute discordance >10mmHg, and discharge echocardiographic mean-gradient ≥20mmHg <br /><b>Results:</b><br/>5027 patients were included in the registry; 4725 native-TAVR and 302 ViV-TAVR. Intra-procedural concomitant echocardiographic and invasive mean-gradients were obtained pre-TAVR in AS (N=2418), pre-ViV-TAVR in SVD (N=101), in 77 post-ViV-TAVR, and in 823 post-TAVR. Echocardiographic and invasive mean-gradients demonstrated strong correlation (r=0.69) and agreement (bias: 0.11, 95% confidence interval (CI) -0.4-0.62) in AS, moderate correlation (r=0.56) and agreement (bias:1.08, 95% CI -2.53-4.59) in SVD, moderate correlation (r=0.61) and weak agreement (bias:6.47, 95% CI 5.08-7.85) post-ViV-TAVR, and weak correlation (r=0.18) and agreement (bias:3.41, 95% CI 3.16-3.65) post-TAVR. Absolute discordance occurs primarily in ViV-TVR, is not explained by STJ size, and increases with increasing echocardiographic mean gradient. Percent discordance in AS and SVD (1.3% and 4%, respectively) was lower compared to post-TAVR/ViV-TAVR (66.7% and 100%, respectively). Compared to self-expanding valves, balloon-expandable valves were independently associated with elevated discharge echocardiographic but lower invasive mean-gradient (odds ratio=3.411, 95% CI:1.482-7.852, p= 0.004 vs. OR=0.308, 95% CI:0.130-0.731, p=0.008, respectively).<br /><b>Conclusions</b><br />Post TAVR/ViV-TAVR, echocardiography is discordant from invasive mean-gradients and absolute discordance increases with increasing echocardiographic mean-gradient and is not explained by STJ size. Percent discordance is significantly higher post-TAVR/ViV-TAVR than in AS and SVD. Post-TAVR/ViV-TAVR, poor correlation and wide limits of agreement suggest echocardiographic and invasive mean-gradients may not be used interchangeably and a high residual echocardiographic mean-gradient should be confirmed invasively before considering any additional procedure to \"correct\" the gradient. TAVR valve types have variable impact on echocardiographic and invasive mean-gradients.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 26 Jul 2023; epub ahead of print</small></div>

<div><h4>Normal Values and Reference Ranges for the Ratio of Transmitral Early Filling Velocity to Early Diastolic Strain Rate - The Copenhagen City Heart Study.</h4><i>Lassen MCH, Skaarup KG, Johansen ND, Olsen FJ, ... Møgelvang R, Biering-Sørensen T</i><br /><b>Background</b><br />The ratio of transmitral early filling velocity to early diastolic strain rate (E/e\'sr) has recently emerged as a measure of left ventricular filling pressure. Reference values are needed for this new parameter for it to be used clinically.<br /><b>Methods</b><br />Healthy participants from a prospective general population study, the 5<sup>th</sup> Copenhagen City Heart Study, were used to establish reference values for E/e\'sr derived from two-dimensional speckle tracking echocardiography. The prevalence of abnormal E/e\'sr was assessed in participants with cardiovascular risk factors or specific diseases.<br /><b>Results</b><br />The population comprised 1,623 healthy participants (median age: 45, IQR: 32-56, 61% females). The upper reference limit for E/e\'sr in the population was 79.6cm. Following multivariable adjustment, males exhibited significantly higher E/e\'sr than females (upper reference limit for males: 83.7cm and for females: 76.5cm). For both sexes, E/e\'sr increased in a curvilinear fashion with age such that the largest increases in E/e\'sr were observed in participants >45years. In the entire CCHS5 population with E/e\'sr available (n=3,902), increasing age, BMI, systolic blood pressure, male sex, eGFR, and diabetes were associated with E/e\'sr (all p<0.05). Total cholesterol was associated with a less steep increase in E/e\'sr. Abnormal E/e\'sr was seldomly observed in participants with normal diastolic function but became more frequent in participants with increasing grades of diastolic dysfunction (normal, mild, moderate, severe (abnormal E/e\'sr in normal, mild, moderate, and severe diastolic dysfunction; 4.4% vs. 20.0% vs. 16.2% vs. 55.6%).<br /><b>Conclusion</b><br />E/e\'sr differ between sexes and is age dependent such that E/e\'sr increases with advancing age. Therefore, we established sex- and age-stratified reference values for E/e\'sr.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 28 Jun 2023; epub ahead of print</small></div>

<div><h4>CLINICAL VALUE OF A NOVEL THREE-DIMENSIONAL ECHOCARDIOGRAPHY DERIVED INDEX OF RIGHT VENTRICLE-PULMONARY ARTERY COUPLING IN TRICUSPID REGURGITATION.</h4><i>Gavazzoni M, Badano LP, Cascella A, Heilbron F, ... Parati G, Muraru D</i><br /><b>Aims</b><br />Echocardiographic surrogates of right ventricle (RV) to pulmonary artery (PA) coupling have been reported to be associated with outcomes in secondary tricuspid regurgitation (STR). However, pulmonary artery systolic pressure (PASP) is difficult to estimate using echocardiography in patients with severe STR. The aim of the present study was to evaluate the predictive power of a surrogate of RV/PA coupling obtained using RV volumes measured by three-dimensional echocardiography (3DE).<br /><b>Methods and results</b><br />We included 180 patients (73±13 years, 61% women) with moderate or severe STR. At a median follow-up of 24 months (IQR: 2-48), 72 patients (40%) reached the composite endpoint of death from any cause and heart failure (HF) hospitalization. We computed RV-PA coupling as the ratio between RV forward stroke volume (SV) [i.e., RV stroke volume (SV) - regurgitant volume] and RV end-systolic volume (ESV). RV forward SV/ESV was significantly more related to the composite endpoint than RVEF (AUC 0.85[95%CI 0.78-0.93] vs. 0.73 [95%CI 0.64-0.83], respectively; p= 0.03). A value of 0.40 was found as the best correlated with outcome. At multivariate Cox-regression, RV forward SV/ESV, TAPSE/PASP, and RVFWLS/PASP were all independently associated with the occurrence of the composite endpoint when added to a group of parameters including STR severity (severe vs moderate), atrial fibrillation, pulmonary arterial hypertension, right atrial volume, RV end-diastolic volume, and RV free-wall longitudinal strain. RV forward SV/ESV<0.40 carried higher related risk than RVFWLS/PASP<-0.42 %/mmHg, and TAPSE/PASP<0.36 mm/mmHg (HR 3.36, CI 95% 1.49-7.56, P <0.01 vs HR 3.1, CI95% 1.26-7.84, P=0.01 and HR 2.69, CI9% 1.29-5.58, P=0.01, respectively). RV ejection fraction did not correlate independently with prognosis when added to the same group of variables.<br /><b>Conclusions</b><br />RV forward SV/ESV is associated with the risk of death and HF hospitalization in patients with STR.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>Lung Ultrasound, Echocardiography and Fluid Challenge for the Differential Diagnosis of Pulmonary Hypertension.</h4><i>D\'Alto M, Liccardo B, Di Maio M, Del Giudice C, ... Golino P, Naeije R</i><br /><b>Aims</b><br />The differential diagnosis between pulmonary arterial hypertension (PAH) and post-capillary pulmonary hypertension (PH) on heart failure with preserved ejection fraction (HFpEF) is sometimes difficult in spite of guidelines-derived standardized step-by-step diagnostic algorithms. We therefore explored the added value of lung ultrasound to previously validated echocardiographic score to right heart catheterization measurements.<br /><b>Methods</b><br />Patients referred for PH underwent a right heart catheterization, echocardiography and lung ultrasound before and after rapid infusion of 7 ml/kg of saline. A 7-point echocardiographic score based on cardiac chamber dimensions and estimates of filling pressures was implemented for the prediction of pre-capillary PH. Pulmonary congestion was identified by lung ultrasound B-lines.<br /><b>Results</b><br />The study enrolled 70 patients with PAH and 77 patients with HFpEF. The PAH patients had a higher echocardiographic score (3.5±1.8 vs 1.6±1.5, p <0.001). The HFpEF patients had more B-lines both before (8.1±4.2 vs 5.1±3.0; p <0.001) and after fluid challenge (14.6±5.4 vs 7.6±3.5; p <0.001), and a more important increase (Δ) of B-lines after fluid challenge (6.5±2.9 vs 2.5±1.6; p <0.001). The sensitivity and specificity of the echocardiographic score (cut off ≥2) alone for PAH were 0.91 and 0.49 respectively [area under the curve (AUC) 0.78]. The best diagnostic improvement was observed with addition of ΔB lines + E/e\' post fluid challenge to the echocardiographic score, with a significant increase of the AUC (0.98), and (with a cut-off given by the presence of: Echo score ≥ 2 and ΔB lines <4 or E/e\' post < 11) a sensitivity of 0.90 (95% CI 0.83;0.97) and specificity 0.84 (95% CI 0.76;0.93)] <br /><b>Conclusion:</b><br/>Lung ultrasound combined with echocardiography at baseline and after fluid challenge has an incremental value for the differential diagnosis between PAH and PH-HFpEF.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 04 Aug 2023; epub ahead of print</small></div>

<div><h4>Echocardiographic pattern of abnormal septal motion: beyond myocardial ischemia.</h4><i>Manganaro R, Cusmà-Piccione M, Carerj S, Licordari R, Khandheria BK, Zito C</i><br /><AbstractText>Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement relies not only on contractile properties but is also affected by the pressure gradient between the two ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 11 Aug 2023; epub ahead of print</small></div>

<div><h4>Insights into the Standard Echocardiographic Views from Multimodality Imaging: Ventricles, Pericardium, Valves, and Atria.</h4><i>Aurigemma GP, Gentile BA, Dickey JB, Fitzgibbons TP, ... Gerson DS, Parker MW</i><br /><AbstractText>The widespread use of cardiac computed tomography (CT) and cardiac MRI (cMR) in patients undergoing echocardiography presents an opportunity to correlate the images side-by-side. Accordingly, the aim of this paper is to review aspects of the standard echocardiographic examination alongside similarly oriented images from the two tomographic imaging modalities. It is hoped that this exercise will enhance the understanding of the structures depicted by echocardiography as they relate to other structures in the thorax. In addition to reviewing basic cardiac anatomy, this paper takes advantage of these correlations with CT and cMR to better understand the issue of foreshortening, a common pitfall in transthoracic echocardiography (TTE). We also highlight an important role that three-dimensional echocardiography can potentially play in the future, especially as advances in image processing permit higher fidelity multiplanar reconstruction images.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 05 Aug 2023; epub ahead of print</small></div>

<div><h4>ChatGPT Helped Me Write This Talk Title, but Can It Read an Echocardiogram?</h4><i>Arnaout R</i><br /><AbstractText>While multidisciplinary collaboration in echocardiography is not new, machine learning has the potential to further improve it. In this transcript of the ASE 2023 Annual Feigenbaum lecture, advancements in foundation models are discussed, including their advantages, current disadvantages, and future potential for echocardiography.</AbstractText><br /><br />Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Soc Echocardiogr: 26 Jul 2023; epub ahead of print</small></div>

<div><h4>Multimodality Imaging in Differentiating Constrictive Pericarditis from Restrictive Cardiomyopathy: A Comprehensive Overview for Clinicians and Imagers.</h4><i>Lloyd JW, Anavekar NS, Oh JK, Miranda WR</i><br /><AbstractText>In the evaluation of heart failure, two differential diagnostic considerations include constrictive pericarditis and restrictive cardiomyopathy. The often outwardly similar clinical presentation of these two pathologic entities routinely renders their clinical distinction difficult. Consequently, initial assessment requires a keen understanding of their separate pathophysiology, epidemiology, and hemodynamic effects. Following a detailed clinical evaluation, further assessment initially rests on comprehensive echocardiographic investigation, including detailed Doppler evaluation. With the combination of mitral inflow characterization, tissue Doppler assessment, and hepatic vein interrogation, initial differentiation of constrictive pericarditis and restrictive cardiomyopathy is often possible with high sensitivity and specificity. In conjunction with a compatible clinical presentation, successful differentiation enables both an accurate diagnosis and subsequent targeted management. In certain cases, however, the diagnosis remains unclear despite echocardiographic assessment, and additional evaluation is required. With advances in noninvasive tools, such evaluation can often continue in a stepwise, algorithmic fashion noninvasively, including both cross-sectional and nuclear imaging. Should this additional evaluation itself prove insufficient, invasive assessment with appropriate expertise may ultimately be necessary.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 22 Aug 2023; epub ahead of print</small></div>

<div><h4>INFLUENCE OF ATHEROSCLEROTIC RISK FACTORS ON THE EFFECTIVENESS OF THERAPEUTIC ULTRASOUND CAVITATION FOR FLOW AUGMENTATION.</h4><i>Belcik JT, Xie A, Muller M, Lindner JR</i><br /><b>Background</b><br />Shear created by inertial cavitation of microbubbles by ultrasound augments limb and myocardial perfusion, and can reverse tissue ischemia. Our aim was to determine whether this therapeutic bioeffect is attenuated by atherosclerotic risk factors known to impair shear-mediated vasodilation and adversely affect microvascular reactivity.<br /><b>Methods</b><br />In mice, lipid-stabilized decafluorobutane microbubbles (2×10<sup>8</sup>) were administered intravenously while exposing a proximal hindlimb to ultrasound (1.3 MHz, 1.3 mechanical index, pulsing interval 5 seconds) for ten minutes. Murine strains included wild-type mice and severely hyperlipidemic (DKO) mice at 15, 35 or 52 weeks-of-age as a model of aging and elevated cholesterol, and obese db/db mice (≈15 weeks) with severe insulin resistance. Quantitative contrast-enhanced ultrasound perfusion imaging was performed to assess microvascular perfusion in the control and US-exposed limb. An in situ electrochemical probe and in vivo biophotonic imaging were used to assess limb nitric oxide (NO) and ATP concentrations, respectively.<br /><b>Results</b><br />Microvascular perfusion was significantly increased by several-fold in the cavitation-exposed limb versus control limb for all murine strains and ages (p<0.001). In wild-type and hyperlipidemic DKO mice, hyperemia from cavitation was attenuated in the two older age groups (p<0.01). In young mice (15 weeks), perfusion in cavitation-exposed muscle was less in both the DKO mice and the obese db/db mice compared to corresponding wild-type mice. Using young DKO mice as a model for flow impairment, limb NO production after cavitation was reduced but ATP production was unaltered when compared to age-matched wild-type mice.<br /><b>Conclusions</b><br />In mice, ultrasound cavitation of microbbubbles increases limb perfusion several fold even in the presence of traditional atherosclerotic risk factors. However, older age, hyperlipidemia, and insulin resistance modestly attenuate the degree of flow augmentation which could impact the degree of flow response in current clinical trials in patient with critical limb ischemia.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Association between left ventricular apical-to-basal strain ratio and conduction disorders after aortic valve replacement.</h4><i>Laenens D, Stassen J, Galloo X, Myagmardorj R, Marsan NA, Bax JJ</i><br /><b>Background</b><br />The aim of the study was to evaluate whether left ventricular apical-to-basal longitudinal strain differences, representing advanced basal interstitial fibrosis, are associated with conduction disorders after aortic valve replacement (AVR) in patients with severe aortic stenosis.<br /><b>Methods</b><br />Patients with aortic stenosis undergoing AVR were included. The apical-to-basal strain ratio was calculated by dividing the average strain of the basal segments by the average strain of the apical segments. Values >1.9 were considered abnormal, as previously described. All patients were followed-up for the occurrence of complete left or right bundle branch block, or permanent pacemaker implantation within 2 years after AVR. Subgroup analysis was performed in patients undergoing transcatheter AVR.<br /><b>Results</b><br />Two hundred seventy-four patients were included (74 years (IQR 65, 80), 46.4% male). During a median follow-up of 12.2 months (IQR 0.2, 24.3), 74 patients (27%) developed complete bundle branch block or were implanted with a permanent pacemaker. These patients more often had an abnormal apical-to-basal strain ratio. Cumulative event-free survival analysis showed worse outcome in patients with an abnormal apical-to-basal strain ratio (Log rank χ<sup>2</sup> 7.258, p = 0.007). In multivariable cox regression analysis, an abnormal apical-to-basal strain ratio was the only independent factor associated with the occurrence of complete bundle branch block or permanent pacemaker implantation after adjusting for other factors previously shown to be associated with conduction disorders after AVR. Subgroup analysis confirmed the independent association of an abnormal apical-to-basal strain ratio with conduction disorders after transcatheter AVR.<br /><b>Conclusion</b><br />The apical-to-basal strain ratio is independently associated with conduction disorders after AVR and could guide risk stratification in patients potentially at risk for pacemaker implantation.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 18 Sep 2023; epub ahead of print</small></div>

<div><h4>Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA study.</h4><i>Davis EF, Crousillat DR, Peteiro J, Lopez-Sendon J, ... Reynolds HR, CIAO-ISCHEMIA Research Group</i><br /><b>Background</b><br />Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA).<br /><b>Objectives</b><br />To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA.<br /><b>Methods</b><br />Left ventricular GLS was calculated offline on resting SE images at enrollment (n=144) and 1-year follow-up (n=120) in the CIAO-ISCHEMIA study, which enrolled participants with moderate or severe ischemia by local SE interpretation (>3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) CAD on coronary CT angiography.<br /><b>Results</b><br />GLS values were normal in 83.3% at enrollment and 94.2% at follow-up. GLS values were not associated with a positive SE at enrollment (GLS -21.5% positive SE vs. GLS -19.9% negative SE, p=0.443), or follow-up (GLS -23.2% positive SE vs. GLS -23.1% negative SE, p=0.859). Significant change in GLS was not associated with positive SE in follow-up (p=0.401). Regional strain was not associated with co-localizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β=0.41, 95% CI 0.16, 0.67, p=0.002).<br /><b>Conclusions</b><br />In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 16 Sep 2023; epub ahead of print</small></div>