Showing papers in "Journal of The American Society of Echocardiography in 2019"

Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography.

Abstract: Carol Mitchell, PhD, ACS, RDMS, RDCS, RVT, RT(R), FASE, Co-Chair, Peter S. Rahko, MD, FASE, Co-Chair, Lori A. Blauwet, MD, FASE, Barry Canaday, RN, MS, RDCS, RCS, FASE, Joshua A. Finstuen, MA, RT(R), RDCS, FASE, Michael C. Foster, BA, RCS, RCCS, RDCS, FASE, Kenneth Horton, ACS, RCS, FASE, Kofo O. Ogunyankin, MD, FASE, Richard A. Palma, BS, RDCS, RCS, ACS, FASE, and Eric J. Velazquez, MD, FASE,Madison, Wisconsin; Rochester, Minnesota; Klamath Falls, Oregon; Durham, North Carolina; Salt Lake City, Utah; Ikoyi, Lagos, Nigeria; and Hartford, Connecticut

Guidelines for the Evaluation of Valvular Regurgitation After Percutaneous Valve Repair or Replacement: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardiography, and Society for Cardiovascular Magnetic Resonance

Abstract: The followi document: MD, FASE; sukochi, M following a M. Asch, M core lab pro tis, Abbott/ DirectFlow D. Gillam,M tronic; Pau dyne and r Medtronic, Guidelines for the Evaluation of Valvular Regurgitation After Percutaneous Valve Repair or Replacement A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardiography, and Society for Cardiovascular Magnetic Resonance

Global Myocardial Work Is Superior to Global Longitudinal Strain to Predict Significant Coronary Artery Disease in Patients With Normal Left Ventricular Function and Wall Motion.

Abstract: Background: Noninvasive detection of functionally significant coronary artery disease (CAD)by echocardiography remains challenging, with the need to perform stress imaging to detect ischemia. The aim of this study was to determine whether global myocardial work (MW), derived from noninvasive left ventricular (LV)pressure-strain loops at rest, can predict significant CAD in patients without regional wall motion abnormalities and preserved LV ejection fraction (EF). Methods: One hundred and fifteen patients referred for coronary angiography who had EF ≥ 55%, no resting regional wall motion abnormalities, and no chest pain were assessed using echocardiography. Global MW was derived from noninvasive LV pressure-strain loops constructed from speckle-tracking echocardiography indexed to brachial systolic blood pressure. Global constructive work represented the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation. Global wasted work represented energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation. Global MW efficiency was derived from the percentage ratio of constructive work to the sum of constructive work and wasted work. Results: Patients with significant CAD demonstrated a significantly reduced global MW (P <.001)compared with those without CAD. Global longitudinal strain was significantly reduced (P <.001)in patients with multivessel CAD but not those with single-vessel CAD (P =.47). Receiver operating characteristic curve analysis demonstrated that global MW was the most powerful predictor of significant CAD (area under the curve = 0.786)and was superior to global longitudinal strain (area under the curve = 0.693). The optimal cutoff global MW value to predict significant CAD was 1,810 mm Hg% (sensitivity, 92%; specificity, 51%). Conclusions: Noninvasive global MW derived using LV pressure-strain loops at rest is a more sensitive index than global longitudinal strain to detect significant CAD in patients with no regional wall motion abnormalities and normal EF. This is a potential valuable clinical tool to assist in the early diagnosis of CAD.

Similarities and Differences in Left Ventricular Size and Function among Races and Nationalities: Results of the World Alliance Societies of Echocardiography Normal Values Study.

Abstract: Background The World Alliance Societies of Echocardiography (WASE) Normal Values Study evaluates individuals from multiple countries and races with the aim of describing normative values that could be applied to the global community worldwide and to determine differences and similarities among people from different countries and races. The present report focuses specifically on two-dimensional (2D) left ventricular (LV) dimensions, volumes, and systolic function. Methods The WASE Normal Values Study is a multicenter international, observational, prospective, cross-sectional study of healthy adult individuals. Participants recruited in each country were evenly distributed among six predetermined subgroups according to age and gender. Comprehensive 2D transthoracic echocardiograms were acquired and analyzed following strict protocols based on recent American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines. Analysis was performed at the WASE 2D core laboratory and included 2D LV dimensions, LV volumes, and LV ejection fraction (LVEF) by the biplane Simpson method and global longitudinal strain (GLS). Results Two thousand eight subjects were enrolled in 15 countries. The median age was 45 years (interquartile range, 32–65 years), 42.8% were white, 41.8% were Asian, and 9.7% were black. LV dimensions and volumes were larger in male subjects, while LVEF and GLS were higher in female subjects. Global WASE normal ranges for LV dimensions were smaller than those in the guidelines, but the upper limits of normal for LV volumes and the lower limits of normal for LVEF were higher in the WASE study. Significant intercountry variation was identified for all LV parameters reflecting LV size (dimensions, mass, and volumes) even after indexing to body surface area, with LV end-diastolic and end-systolic volumes having the highest variation. The largest volumes were noted in Australia, while the smallest were measured in India for both genders. This finding suggests that in addition to gender and body surface area, specific country should be considered when evaluating LV volumes. Intercountry variation for LVEF and GLS was smaller but still statistically significant (P Conclusions LV dimensions and volumes are larger in men, while LVEF and GLS are higher in women. Current guideline-recommended normal ranges for LV volumes and LVEF should be adjusted. Intercountry variability is significant for LV volumes, and therefore nationality should be considered for defining ranges of normality.

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic: Examination in Children and All Patients with Congenital Heart Disease: Recommendations from the American Society of Echocardiography.

Abstract: Michael D. Puchalski, (Chair), MD, FASE, George K. Lui, MD, FASE, Wanda C. Miller-Hance, MD, FASE, Michael M. Brook, MD, FASE, Luciana T. Young, MD, FASE, Aarti Bhat, MD, FASE, David A. Roberson, MD, FASE, Laura Mercer-Rosa, MD, MSCE, Owen I. Miller, BMed (Hons), FRACP, David A. Parra, MD, FASE, Thomas Burch, MD, Hollie D. Carron, AAS, RDCS, ACS, FASE, and Pierre C. Wong, MD, Salt Lake City, Utah; Stanford, San Francisco and Los Angeles, California; Houston, Texas; Seattle, Washington; Chicago, Illinois; Philadelphia, Pennsylvania; London, United Kingdom; Nashville, Tennessee; Boston, Massachusetts; and Kansas City, Missouri

A Practical Guide to Assess the Reproducibility of Echocardiographic Measurements

Abstract: Echocardiography plays an essential role in the diagnosis and assessment of cardiovascular disease. Measurements derived from echocardiography are also used to determine the severity of disease, its progression over time, and to aid in the choice of optimal therapy. It is therefore clinically important that echocardiographic measurements be reproducible, repeatable, and reliable. There are a variety of statistical tests available to assess these parameters, and in this article the authors summarize those available for use by echocardiographers to improve their clinical practice. Correlation coefficients, linear regression, Bland-Altman plots, and the coefficient of variation are explored, along with their limitations. The authors also provide an online tool for the easy calculation of these statistics in the clinical environment (www.birmingham.ac.uk/echo). Quantifying and enhancing the reproducibility of echocardiography has important potential to improve the value of echocardiography as the basis for good clinical decision-making.

Global Left Ventricular Myocardial Work Efficiency in Healthy Individuals and Patients with Cardiovascular Disease

Abstract: Background Global left ventricular (LV) myocardial work efficiency, the ratio of constructive to wasted work in all LV segments, reflects the efficiency by which mechanical energy is expended during the cardiac cycle. Global LV myocardial work efficiency can be derived from LV pressure-strain loop analysis incorporating both noninvasively estimated blood pressure recordings and echocardiographic strain data. The aim of this study was to characterize global LV myocardial work efficiency in healthy individuals and patients with cardiovascular (CV) risk factors or overt cardiac disease. Methods We retrospectively included healthy individuals without structural heart disease or CV risk factors, who were selected from an ongoing database of normal individuals, and matched for age and sex with (1) individuals without structural heart disease but with CV risk factors, (2) postinfarct patients without heart failure, and (3) heart failure patients with reduced ejection fraction (HFrEF). Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. Results In total, 120 individuals (44% male, 53 ± 13 years) were included (n = 30 per group). In healthy individuals without structural heart disease or CV risk factors, global LV myocardial work efficiency was 96.0% (interquartile range, 95.0%-96.3%). Myocardial efficiency of the LV did not differ significantly between individuals without structural heart disease and those with CV risk factors (96.0% vs 96.0%; P = .589). Global LV myocardial work efficiency, however, was significantly decreased in postinfarct patients (96.0% vs 93.0%, P Conclusions While global LV myocardial work efficiency was similar in normal individuals and in those with CV risk factors, it was decreased in postinfarct and HFrEF patients. The global LV myocardial work efficiency values presented here show distinct patterns in different cardiac pathologies.

Pathophysiology and Echocardiographic Diagnosis of Left Ventricular Diastolic Dysfunction.

Abstract: Echocardiography is the primary imaging modality used for the clinical evaluation of left ventricular (LV) diastolic function. Using two-dimensional together with transmitral, mitral annular, and pulmonary venous Doppler data, conclusions may be drawn regarding the relaxation and compliance properties of the ventricle that can be used for estimating LV filling pressure. Echocardiographic estimation of LV filling pressure has been shown to be especially useful for evaluating patients with dyspnea of unknown etiology as well as those with heart failure with preserved ejection fraction. Moreover, echocardiographic estimation of LV filling pressure can be used for clinical decision making on day-to-day basis. This article discusses the pathophysiology of diastolic dysfunction and provides a comprehensive review of its echocardiographic evaluation.

Machine Learning-Based Three-Dimensional Echocardiographic Quantification of Right Ventricular Size and Function: Validation Against Cardiac Magnetic Resonance.

Abstract: Background Three-dimensional echocardiography (3DE) allows accurate and reproducible measurements of right ventricular (RV) size and function. However, widespread implementation of 3DE in routine clinical practice is limited because the existing software packages are relatively time-consuming and skill demanding. The aim of this study was to test the accuracy and reproducibility of new machine learning– (ML-) based, fully automated software for three-dimensional quantification of RV size and function. Methods Fifty-six unselected patients with a wide range of RV size and function and image quality, referred for clinically indicated cardiac magnetic resonance (CMR) imaging, underwent a transthoracic 3DE exam on the same day. End-systolic and end-diastolic RV volumes (ESV, EDV) and ejection fraction (EF) were measured using the ML-based algorithm and compared with CMR reference values using Bland-Altman and linear regression analyses. Results RV function quantification by echocardiography was feasible in all patients. The automatic approach was accurate in 32% patients with analysis time of 15 ± 1 seconds and 100% reproducible. Endocardial contour editing was necessary after the automated postprocessing in the remaining 68% patients, prolonging analysis time to 114 ± 71 seconds. With these minimal adjustments, RV volumes and EF measurements were accurate in comparison with CMR reference (biases: EDV, −25.6 ± 21.1 mL; ESV, −7.4 ± 16 mL; EF, −3.3% ± 5.2%) and showed excellent reproducibility reflected by coefficients of variation Conclusions The new ML-based 3DE algorithm provided accurate and completely reproducible RV volume and EF measurements in one-third of unselected patients without any boundary editing. In the remaining patients, quick minimal editing resulted in reasonably accurate measurements with excellent reproducibility. This approach provides a promising solution for fast three-dimensional quantification of RV size and function.

Left Atrial Function Predicts Cardiovascular Events in Patients With Chronic Heart Failure With Reduced Ejection Fraction.

Abstract: Background Heart failure (HF) is known to be the most widespread epidemic of cardiovascular disease. Among several factors with prognostic value for the clinical course of HF, left atrial (LA) function has not yet been fully examined. The aim of this prospective study was to evaluate LA function for the prediction of major cardiovascular outcomes in stable patients with chronic HF with reduced ejection fraction. Additionally, as secondary end points, cardiovascular mortality and atrial fibrillation were analyzed separately. Methods The predictive value of LA function evaluated by speckle-tracking echocardiography was assessed in a population of 286 outpatients referred to the authors’ institution for routine evaluation of chronic HF. Global peak atrial longitudinal strain was measured at the end of the reservoir phase and calculated by averaging in all LA segments. Results During a median follow-up period of 48 ± 11 months, major adverse cardiac events occurred in 98 patients (34%). In a multivariate model, global peak atrial longitudinal strain (hazard ratio, 0.95; 95% CI, 0.94–0.96; P = .02), left ventricular ejection fraction (hazard ratio, 0.95; 95% CI, 0.93–0.97; P = .01), and renal failure (hazard ratio, 0.98; 95% CI, 0.97–0.99; P = .01) were independent predictors of an adverse outcome. Sixty-six patients (23%) died of cardiac causes. Fifty-four patients (19%) developed atrial fibrillation. Patients with lower global peak atrial longitudinal strain showed worse event-free survival and developed atrial fibrillation more frequently than those with higher levels. Conclusions LA function assessed by speckle-tracking echocardiography is an independent prognostic marker in patients with HF with reduced ejection fraction.

Low Left Atrial Strain Is Associated With Adverse Outcomes in Hypertrophic Cardiomyopathy Patients

Abstract: Background Paroxysmal atrial fibrillation (PAF) and left atrial (LA) structural remodeling are common in hypertrophic cardiomyopathy (HCM) patients, who are also at risk for adverse cardiovascular outcomes. Objective We assessed whether PAF and/or LA remodeling was associated with adverse outcomes in HCM. Methods We retrospectively studied 45 HCM patients with PAF (PAF group) and 59 HCM patients without atrial fibrillation (AF; no-AF group). LA/left ventricular (LV) function and mechanics were assessed by echocardiography. Patients were followed for development of the composite endpoint comprising heart failure, stroke, and death. Results Clinical/demographic characteristics, degree of LV hypertrophy, and E/e′ were similar in the two groups The PAF group had significantly higher LA volume, but lower LA ejection fraction (LAEF), LA contractile, and reservoir strain/strain rate than the no-AF group. During follow-up, 27 patients developed the composite endpoint. Incidence of the composite endpoint was similar in the two groups. Absolute values of 23.8% for reservoir strain and 10.2% for conduit strain were the best cutoffs for the composite endpoint, using receiver operating characteristic analysis. Kaplan-Meier survival analysis showed lower event-free survival in patients with reservoir strain ≤23.8% or conduit strain ≤10.2%. Univariate Cox analysis revealed an association between female sex, LAEF, LA reservoir/conduit strain, and LV global longitudinal strain with the composite endpoint. The association between LA reservoir/conduit strain and the composite endpoint persisted after controlling for age, sex, LAEF, and LV global longitudinal strain. Conclusions In this pilot HCM patient study, PAF was associated with a greater degree of LA myopathy, and low LA reservoir and conduit strain were associated with higher risk for adverse cardiovascular outcomes.

Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System

Abstract: Background Transcatheter closure of patent foramen ovale (PFO) has become an effective therapeutic strategy for cryptogenic stroke (CS). The identification of high-risk PFO is essential, but the data are limited. This study aimed to clarify the factors related to CS and to develop a score for high-risk PFO. Methods We retrospectively analyzed 57 patients with prior CS and 50 without CS who were scheduled for transcatheter closure. PFO characteristics were evaluated by transesophageal echocardiography. Based on factors related to CS, we estimated the risk score. Results Patients with CS had a greater frequency of large-size PFO (≥2 mm in height), long-tunnel PFO (≥10 mm in length), atrial septal aneurysm, hypermobile interatrial septum, prominent Eustachian valve or Chiari's network, the large right-to-left shunt at rest and during Valsalva maneuver, and low-angle PFO (≤10° of PFO angle from inferior vena cava), compared with patients without CS. Multivariate analysis showed that long-tunnel PFO, the presence of hypermobile interatrial septum, the presence of prominent Eustachian valve or Chiari's network, the large right-to-left shunt during Valsalva maneuver, and low-angle PFO were independently related to CS. When the score was estimated based on 1 point for each factor, the proportion of CS was markedly elevated with a score of ≥2 points. The probability of CS was markedly different between scores of ≤1 or ≥2 points. Conclusions PFO risk can be assessed with a score based on high-risk features. The presence of two or more high-risk PFO features is associated with CS.

Intracardiac Flow Analysis: Techniques and Potential Clinical Applications.

Abstract: Analysis of intracardiac flows has gained increasing interest in the last years. This analysis has become possible due to the development of technologies for noninvasive cardiovascular imaging, which allow visualization and quantitation of intracardiac flow dynamics. Several studies have shown that abnormalities in cardiac function are related to changes in intracardiac vortical flows. Thus, analysis of cardiac vortex has been used for better understanding of the pathophysiology in many heart diseases and to test initial clinical hypotheses. The aims of this review are to introduce the reader to the topic of intracardiac flow dynamics, to briefly describe current cardiac imaging techniques for analysis of the intracardiac vortex, and to indicate potential clinical applications of a vortex-based approach to the study of cardiac function.

Superior Prognostic Value of Right Ventricular Free Wall Compared to Global Longitudinal Strain in Patients With Heart Failure.

Abstract: Background Global right ventricular (RV) longitudinal strain (RVGLS) and free wall RV longitudinal strain (RVFWS) have both been advocated as sensitive tools to evaluate RV function and predict prognosis in patients with heart failure and reduced ejection fraction (HFrEF). However, because the interventricular septum is an integral part of the left ventricle (LV) also, RVGLS might be influenced by LV dysfunction. Thus, we compared the prognostic performance of either RV strain parameter in HFrEF patients, also taking into account the degree of LV systolic dysfunction. Methods In 288 prospectively enrolled outpatients with stable HFrEF, RVGLS and RVFWS were assessed by speckle-tracking and LV systolic function by global longitudinal strain and LV ejection fraction. Patients were followed up for 30.2 ± 23.0 months; the primary endpoint was all-cause death/heart failure-related hospitalization. Prognostic performance was assessed by C-statistic and net reclassification improvement. Results There were 95 events during follow-up. By univariable analysis, both RVGLS (hazard ratio × 1 SD, 1.60; 95% CI, 1.29-1.99; P Conclusions Although both RVGLS and RVFWS have prognostic value, RVFWS better predicts outcome in HFrEF patients, mainly because it is less influenced by LV longitudinal dysfunction.

Mitral Annular and Left Ventricular Dynamics in Atrial Functional Mitral Regurgitation: A Three-Dimensional and Speckle-Tracking Echocardiographic Study.

Abstract: Background Patients with atrial fibrillation (AF) and left atrial (LA) enlargement may develop functional, normal leaflet motion mitral regurgitation (MR) without left ventricular (LV) remodeling. Mitral annular dynamics and LV mechanics are important for preserving normal mitral valve function. The aim of this study was to assess the annular and LV dynamics in patients with AF and functional MR. Methods Twenty-one patients with AF with moderate or more MR (AFMR+ group), 46 matched patients with AF with no or mild MR (AFMR− group), and 19 normal patients were retrospectively studied. Mitral annular dynamics were quantitatively assessed using three-dimensional echocardiography. Systolic LV global longitudinal strain (GLS), global circumferential strain, and LA strain were measured using two-dimensional speckle-tracking echocardiography. Results The normal annulus displayed presystolic followed by systolic contraction and increase in saddle shape (P .05 vs normal). In contrast, systolic and total annular dynamics during the cardiac cycle were preserved in AFMR− patients (P > .10 vs normal) but impaired in AFMR+ patients (P Conclusions In patients with AF and absent LA contraction, the normal predominantly “atriogenic” annular dynamics become “ventriculogenic.” Isolated LA enlargement is insufficient to cause important MR without coexisting abnormal LV mechanics and annular dynamics during systole. “Atrial” functional MR may not be purely an atrial disorder.

Relative Prognostic Importance of Left and Right Ventricular Ejection Fraction in Patients With Cardiac Diseases.

Abstract: Background The study aimed (1) to assess the prognostic value of three-dimensional echocardiography (3DE) derived right ventricular (RV) ejection fraction (EF) and (2) to evaluate relative prognostic importance of reduced and preserved left ventricular (LV) EF and RVEF to predict all-cause mortality and cardiac death in a large cohort of patients with cardiac diseases. Methods LV and RV volumes and EF were assessed by 3DE in 394 patients with various cardiovascular diseases. Patients were divided into four groups: (1) normal LVEF (≥50%) and normal RVEF (≥45%), n = 183; (2) reduced LVEF ( Results Reduced 3DE-derived RVEF was associated with all-cause mortality (P Conclusions Reduced 3DE-derived RVEF was associated with all-cause mortality and cardiac death in patients with various cardiovascular diseases. Impairment of RVEF carried a significantly higher risk of mortality independent of LVEF.

Device Sizing Guided by Echocardiography-Based Three-Dimensional Printing Is Associated with Superior Outcome after Percutaneous Left Atrial Appendage Occlusion

Abstract: Background Left atrial appendage (LAA) occlusion is an alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. Accurate device sizing is crucial for optimal outcome. Patient-specific LAA models can be created using three-dimensional (3D) printing from 3D transesophageal echocardiographic (TEE) images, allowing in vitro model testing for device selection. The aims of this study were to assess the association of model-based device selection with procedural safety and efficacy and to determine if preprocedural model testing leads to superior outcomes. Methods In 72 patients who underwent imaging-guided LAA occlusion, 3D models of the LAA were created from 3D TEE data sets retrospectively (retrospective cohort). The optimal device determined by in vitro model testing was compared with the actual device used. Associations of model-match and model-mismatch device sizing with outcomes were analyzed. In another 32 patients, device selection was prospectively guided by 3D models in adjunct to imaging (prospective cohort). The impact of model-based sizing on outcomes was assessed by comparing the two cohorts. Results Patients in the retrospective cohort with model-mismatch sizing had longer procedure times, more implantation failures, more devices used per procedure, more procedural complications, more peridevice leak, more device thrombus, and higher cumulative incidence rates of ischemic stroke and cardiovascular or unexplained death (P Conclusions In patients undergoing LAA occlusion, device size selection in agreement with 3D-printed model-based sizing is associated with improved safety and efficacy. Preprocedural device sizing with 3D models in adjunct to imaging guidance may lead to superior outcomes.

Comparison Between Four-Chamber and Right Ventricular-Focused Views for the Quantitative Evaluation of Right Ventricular Size and Function

Abstract: Background Right ventricular (RV) function plays a pivotal prognostic role in multiple cardiac diseases. Echocardiography guidelines recommend that RV quantification be performed in the RV-focused view, which is theoretically more reproducible than the four-chamber (4Ch) view. However, differences between views in RV size and function measurements have never been systematically studied. Accordingly, the aim of this study was to compare (1) RV size and function parameters obtained from the RV-focused and 4Ch views and (2) test-retest variability between these two views. Methods Fifty patients (26 men; mean age, 63 ± 18 years) undergoing clinically indicated transthoracic echocardiography were prospectively enrolled. Each patient underwent three repeated acquisitions of the 4Ch and RV-focused views by two sonographers. The first operator performed two acquisitions at the beginning and the end of the clinical transthoracic echocardiographic study, and the second operator performed the third acquisition afterward. RV size and function measurements were obtained from the two views and compared using paired t-test analysis and Bland-Altman analysis. Intra- and interoperator test-retest and intra- and interreader variability for both views were assessed using intraclass correlations and coefficients of variation. Results All RV size parameters were significantly larger when measured in the RV-focused view compared with the 4Ch view. Also, all RV function parameters, including RV free wall and global longitudinal strain, were larger in magnitude when measured in the RV-focused view. Measurements variability was consistently better for the RV-focused view. Conclusions RV size and function measurements obtained from the RV-focused and 4Ch views are not interchangeable. RV size and function parameters measured from the RV-focused view are more reproducible than from 4Ch acquisitions. Therefore, only the RV-focused view should be used for quantitative assessment of the right ventricle.

Echocardiographic Assessment of Right Ventricular Afterload in Preterm Infants: Maturational Patterns of Pulmonary Artery Acceleration Time Over the First Year of Age and Implications for Pulmonary Hypertension

Abstract: Background Assessment of pulmonary hemodynamics is critical in the diagnosis and management of cardiopulmonary disease of premature infants, but reliable noninvasive indices of pulmonary hemodynamics in preterm infants are lacking. Because pulmonary artery acceleration time (PAAT) is a validated noninvasive method to assess right ventricular (RV) afterload in infants and children, the aim of this study was to investigate the maturational changes of PAAT measures in preterm infants over the first year of age and to discern the impact of typical cardiopulmonary abnormalities on these measures. Methods In a prospective multicenter study of 239 preterm infants ( Results PAAT was feasible in 95% of the image acquisitions, and there was high intra- and interobserver agreement (intraclass correlation coefficients > 0.9 and coefficients of variation 0.81, P Conclusions PAAT measures increase in preterm infants from birth to 1-year corrected age, reflective of the physiologic postnatal drop in RV afterload. Bronchopulmonary dysplasia and pulmonary hypertension have a negative impact on PAAT measures. By demonstrating excellent reliability and establishing reference patterns of PAAT in preterm infants, this study suggests that PAAT and PAAT adjusted for RV ejection time can be used as complementary parameters to assess physiologic and pathologic changes in pulmonary hemodynamics in neonates.

Need for a Global Definition of Normative Echo Values-Rationale and Design of the World Alliance of Societies of Echocardiography Normal Values Study (WASE).

Abstract: In cardiac imaging, as in any other medical discipline, understanding what is ‘‘normal’’ within a population is fundamental to define the concept of abnormal. While this is straightforward in the presence of a tumor (a yes/no assessment) or an abnormal blood count, defining normal dimensions of cardiac chambers or the normal values of cardiac function poses a significant challenge. Echocardiography is themost widely used imagingmodality to assess cardiac size and function, but despite the importance of having ‘‘reference limits’’ to define normal cardiac structure and function in echocardiography, the currently available studies fail to reflect the diversity of populations from around the world. The American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI) have recently taken a significant step into defining ‘‘normality’’ in echocardiography. The ASE/EACVI chamber quantification recommendations update published in 2015 made significant progress relative to its previous 2005 version by including normal values and ranges for a variety of left ventricular (LV), right ventricular (RV), right atrial (RA), and left atrial (LA) measurements frequently reported in standard echocardiographic reports. These reference values have been derived by accessing the data from a variety of well-designed population-based studies. However, the meta-analysis performed to obtain the normal values in the ASE/EACVI document has several limitations, mostly related to the lack of representation of the wider global international community. First, as seen in Table 1, the vast majority of subjects were Caucasian. Few subjects of black race were enrolled, and no Latinos, Asians, or Africans were included in these studies. Second,

Left Atrial Mechanical Dispersion Assessed by Strain Echocardiography as an Independent Predictor of New-Onset Atrial Fibrillation: A Case-Control Study

Abstract: Background Left atrial (LA) enlargement is associated with atrial fibrillation (AF), but new-onset AF often occurs in the absence of LA enlargement. AF may be related to myocardial fibrosis, and even though left ventricular fibrosis is associated with mechanical dispersion, this phenomenon is not well studied in AF. We hypothesized that detection of LA dysfunction and mechanical dispersion using strain echocardiography is useful for predicting new-onset AF. Methods Baseline echocardiography was performed at entry in 576 community-based participants at risk of heart failure or AF. In this case-control study, we compared 35 individuals with new-onset AF (age 70 ± 4 years; 57% men) over 2 years of follow-up with 35 age- and sex-matched individuals who did not develop AF from the same cohort. Using speckle-tracking echocardiography, we measured the LA strain in each of 12 segments in the two- and four-chamber views. LA mechanical dispersion was defined as the SD of time to peak positive strain corrected by the R-R interval (SD-TPS, %). Results There was no significant difference in LA volume index (32.5 ± 9.2 mL/m2 vs 29.5 ± 8.3 mL/m2; P = .16); patients with new-onset AF had significantly worse LA pump strain (16.6% ± 4.3% vs 20.6% ± 4.3%; P Conclusions LA dispersion obtained from strain echocardiography seems to provide incremental information about LA volume and function in the prediction of new-onset AF and warrants testing in a larger study.

Contribution of Cardiovascular Reserve to Prognostic Categories of Heart Failure With Preserved Ejection Fraction: A Classification Based on Machine Learning

Abstract: Background The authors used cluster analysis of data from cardiovascular domains associated with exercise intolerance to help define prognostic phenotypes of patients with heart failure with preserved ejection fraction (HFpEF). Methods Resting and postexercise echocardiography was performed in 177 patients with HFpEF and 51 asymptomatic control subjects sharing a common clinical profile. Patterns of features that determine exercise capacity were sought from automated hierarchical clustering of left ventricular (LV) diastolic and systolic function, left atrial function, right ventricular function, ventricular-arterial coupling, chronotropic reserve and myocardial fibrosis. Results Automated clustering separated a distinct subgroup characterized by a relatively isolated impairment of LV systolic reserve. The clinical factors identified by this process were used to define two phenotypes of patients with symptomatic HFpEF: those with reduced chronotropic and/or diastolic reserve (abnormal CR/DR; n = 137) and those with preserved heart rate reserve and exertional E/e′ ratio Conclusions Diminished LV systolic reserve may represent the major identifiable cardiac functional abnormality associated with exercise intolerance in some patients with HFpEF. Despite significant functional limitation, these patients are characterized by a better prognosis than subjects with HFpEF with more physiologic abnormalities.

Speckle-Tracking Echocardiography in Children With Duchenne Muscular Dystrophy: A Prospective Multicenter Controlled Cross-Sectional Study.

Abstract: Background Prognosis of Duchenne muscular dystrophy (DMD) is related to cardiac dysfunction. Speckle-tracking echocardiographic (STE) imaging is emerging as a noninvasive functional biomarker to consider in the early detection of DMD-related cardiomyopathy. However, STE analysis has not been assessed in a prospectively controlled study, especially in presymptomatic children with DMD, and no study has used STE analysis in all three displacements (longitudinal, radial, and circumferential) and for both ventricles. Methods This prospective controlled study enrolled 108 boys, 36 of whom had DMD (mean age, 11 ± 3.8 years) and 72 of whom were age-matched control subjects in a 1:2 case-control design. Conventional echocardiographic variables were collected for the left and right ventricles. STE analyses were performed in the longitudinal, radial, and circumferential displacements for the left ventricle and in the free wall longitudinal displacement for the right ventricle. The effect of age on the evolution of two-dimensional strain in children with DMD was studied by adding an interaction term, DMD × age, in the models. Results Conventional echocardiographic measures were normal in both groups. Left ventricular (LV) ejection fraction ranged from 45% to 76% (mean, 63 ± 6%) in the DMD group and from 55% to 76% (mean, 64 ± 5%) in the control group. Global LV strain mean measures were significantly worse in the DMD group for the longitudinal (−16.8 ± 3.9% vs −20.6 ± 2.6%, P Conclusions The existence of altered LV strain despite normal LV function in children with DMD represents an important perspective for future pediatric drug trials in DMD-related cardiomyopathy prevention.

Normal Ranges of Left Ventricular Strain by Three-Dimensional Speckle-Tracking Echocardiography in Adults: A Systematic Review and Meta-Analysis.

Abstract: Background Establishing normal values and associated variations of three-dimensional speckle-tracking echocardiography– (3DSTE-) derived left ventricular (LV) strain is necessary for accurate interpretation and comparison of measurements. We aimed to perform a meta-analysis of normal ranges of LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) measurements derived by 3DSTE and to identify confounding factors that may contribute to variance in reported measures. Methods The authors searched four databases, PubMed, Scopus, Embase, and Cochrane Library, through January 2019 using the key terms “left ventricular/left ventricle/left ventricles”, “strain/deformation/speckle tracking”, and “three dimensional/three-dimensional/three-dimension/three dimension/3D”. Studies were included if the articles reported LV strain using 3DSTE in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effects model with a 95% CI. Heterogeneity across studies was assessed using the I2 test. Effects of demographic (age), clinical, and vendor variables were assessed in a metaregression. The National Institutes of Health tools were used to assess the quality of included articles. Publication bias was examined by Begg's funnel plot and Egger's regression test. Results The search yielded 895 articles. After abstract and full-text screening we included 33 data sets with 2,346 patients for meta-analysis. The reported normal mean values of GLS among the studies varied from −15.80% to −23.40% (mean, −19.05%; 95% CI, −18.18% to −19.93%; I2 = 99.0%), GCS varied from −15.50% to −39.50% (mean, −22.42%; 95% CI, −20.96% to −23.89%, I2 = 99.7%), GRS varied from 19.81% to 86.61% (mean, 47.48%; 95% CI, 41.50%-53.46%; I2 = 99.8%), and GAS varied from –27.40% to –50.80% (mean, –35.03%; 95% CI, –33.19% to –36.87%; I2 = 99.3%). Software for strain analysis was consistently associated with variations in normal strain values (GLS: P = .016; GCS: P Conclusions Variations in the normal ranges across studies were significantly associated with the software used for strain analysis, emphasizing that this factor must be considered in the interpretation of strain data.

Assessment of Early Radiation-Induced Changes in Left Ventricular Function by Myocardial Strain Imaging After Breast Radiation Therapy

Abstract: Background Radiation therapy (RT)-induced cardiotoxicity is among the concerning sequelae of breast cancer (BCA) treatment, particularly in HER2-positive BCA patients who receive anthracyclines and trastuzumab-based therapy. The aim of this study was to assess for early RT-induced changes in echocardiographic and circulating biomarkers of left ventricular (LV) function and evaluate their association with radiation dose to the heart among patients with HER2-positive BCA treated with contemporary RT. Methods A total of 47 women with HER2-positive BCA who were treated with an anthracycline, trastuzumab, and RT to the breast and/or chest wall ± regional lymph nodes were included in this study. Two-dimensional echocardiography with speckle-tracking imaging was performed at baseline (prechemotherapy), prior to and after RT (pre-RT and post-RT), and 6 months post-RT. High-sensitivity troponin I (hsTnI) was measured pre-RT and post-RT. Associations between mean heart dose (MHD) and changes in LV function after RT were examined in multivariable linear regression models. Results The MHD was 1.8 ± 1.5 Gy for patients receiving left-sided RT (n = 26) and 1.1 ± 1.3 Gy for patients receiving right-sided RT (n = 21). Pre-RT, post-RT, and 6-month post-RT echocardiograms were performed at median (interquartile range) of 49 days (27, 77) before and 54 days (25, 78) and 195 days (175, 226) after RT, respectively. Compared with pre-RT, a minimal decrease in LV ejection fraction was observed post-RT (61% ± 7% vs 59% ± 8%; P = .003) without any significant change in global longitudinal, circumferential, or radial strain or diastolic indices at the post-RT timepoint. Median (interquartile range) concentrations of hsTnI decreased from 5.7 pg/mL (3.0, 8.7) pre-RT to 3.7 pg/mL (2.0, 5.9) post-RT. There was no significant change in systolic or diastolic indices of LV function at 6 months post-RT compared with pre-RT. MHD was not associated with changes in echocardiographic parameters of LV function after RT. Conclusions Breast RT using contemporary techniques can be delivered without evidence of early subclinical LV dysfunction or injury as measured by echocardiography and hsTnI in patients treated with anthracyclines and trastuzumab. Future studies should focus on identifying alternative biomarkers to elucidate early RT-induced cardiovascular effects and further characterizing long-term cardiovascular outcomes associated with contemporary breast RT.

Dynamic Three-Dimensional Geometry of the Tricuspid Valve Annulus in Hypoplastic Left Heart Syndrome with a Fontan Circulation.

Abstract: Background Tricuspid regurgitation (TR) is a significant contributor to morbidity and mortality in patients with hypoplastic left heart syndrome. The goal of this study was to characterize the dynamic annular motion of the tricuspid valve in patients with HLHS with a Fontan circulation and assess the relation to tricuspid valve function. Methods Tricuspid annuli of 48 patients with HLHS with a Fontan circulation were modeled at end-diastole, mid-systole, end-systole, and mid-diastole using transthoracic three-dimensional echocardiography and custom code in 3D Slicer. The angle of the anterior papillary muscle (APM) relative to the annular plane in each systolic phase was also measured. Results Imaging was performed 5.0 years (interquartile range, 2–11 years) after Fontan operation. The tricuspid annulus varies in shape significantly throughout the cardiac cycle, changing in sphericity (P Conclusions The tricuspid annulus in patients with HLHS with a Fontan circulation changes in shape significantly throughout the cardiac cycle but remains relatively planar. Increased change in septolateral diameter and decreased APM angle are strongly associated with the presence of TR. These findings may inform annuloplasty methods and subvalvular interventions in these complex patients.

Accuracy of Jet Direction on Doppler Echocardiography in Identifying the Etiology of Mitral Regurgitation in Obstructive Hypertrophic Cardiomyopathy

Abstract: Background Mitral valve regurgitation (MR) mediated by systolic anterior motion (SAM) in obstructive hypertrophic cardiomyopathy (HCM) is traditionally characterized by a posteriorly directed jet on Doppler echocardiography. Many believe that MR in the absence of a posteriorly directed jet signals the presence of intrinsic mitral valve (MV) disease. Methods A total of 709 adult patients with obstructive HCM who underwent septal myectomy were evaluated; 330 of these patients had >2 + MR preoperatively and constituted the study group. SAM-mediated MR was defined as MR that was eliminated or substantially reduced by myectomy for relief of left ventricular outflow tract obstruction with no need for MV intervention. Results On preoperative transthoracic echocardiography, 168 of 258 patients with SAM-mediated MR and nine of 28 patients with intrinsic MV disease had isolated posterior jets, corresponding to sensitivity and specificity of 65.1% and 67.9% for identifying SAM-mediated MR; the positive predictive value was 94.9% and the negative predictive value was 17.4%. On prebypass transesophageal echocardiography, 169 of 284 patients with SAM-mediated MR and five of 28 patients with intrinsic MV disease had isolated posterior jets, corresponding to sensitivity and specificity of 59.5% and 82.1%; the positive predictive value and negative predictive value were 97.1% and 16.7%. Conclusion A posteriorly directed jet of MR in obstructive HCM correlates highly with SAM as the underlying pathophysiologic mechanism, but because of the low negative predictive value, clinicians should be cautious in using the jet direction of MR on preoperative transthoracic echocardiography to guide the decision for concomitant MV surgery during septal myectomy for HCM.

Serial Strain Analysis Identifies Hypoplastic Left Heart Syndrome Infants at Risk for Cardiac Morbidity and Mortality: A Pilot Study.

Abstract: Background Validated, objective measures of right ventricular (RV) function assessment in hypoplastic left heart syndrome (HLHS) are needed. In other populations, speckle-tracking echocardiography-derived strain is a sensitive measure that outperforms conventional parameters of RV function. We hypothesized that speckle-tracking echocardiography–derived measures of RV function would be worse in patients with HLHS who have a poor cardiac outcome. Methods Prospective serial echocardiography was performed in 35 infants with HLHS during the first 6 months of life. Patients not undergoing staged palliation or with other variants of single RV were excluded. Traditional RV measurements and strain analysis were performed from standard apical and basal views. The primary outcome of cardiac death, heart transplantation, or persistent ≥ moderate RV dysfunction was examined using Cox regression analysis, and receiver operating characteristic curve analyses were performed to derive cutoff values. Results At median follow-up of 10.9 months (interquartile range 5.6, 15.2), eight patients reached the outcome and demonstrated worse RV strain measures compared with those without the outcome. A post-Norwood global longitudinal strain (GLS) of > –16% (area under the curve [AUC] = 0.76; P = .04) and pre-Glenn GLS > –13% (AUC, 0.98; P ≤ .01) were highly sensitive and specific for poor outcome. Other thresholds included post-Norwood GLS rate (GLSr) > –1.15 %/s (AUC, 0.78; P = .03), pre-Glenn GLSr = –0.85%/sec (AUC, 0.89; P –0.85%/sec (AUC, 0.92; P –0.85%/sec (AUC, 0.84; P = .02). Conclusions Strain analysis may help identify at-risk HLHS infants. In this pilot study, interstage strain indices were worse in infants with HLHS who had a poor cardiac outcome.

Challenges With Left Ventricular Functional Parameters: The Pediatric Heart Network Normal Echocardiogram Database

Abstract: Background The reliability of left ventricular (LV) systolic functional indices calculated from blinded echocardiographic measurements of LV size has not been tested in a large cohort of healthy children. The objective of this study was to estimate interobserver variability in standard measurements of LV size and systolic function in children with normal cardiac anatomy and qualitatively normal function. Methods The Pediatric Heart Network Normal Echocardiogram Database collected normal echocardiograms from healthy children ≤18 years old distributed equally by age, gender, and race. A core lab used two-dimensional echocardiograms to measure LV dimensions from which a separate data coordinating center calculated LV volumes and systolic functional indices. To evaluate interobserver variability, two independent expert pediatric echocardiographic observers remeasured LV dimensions on a subset of studies, while blinded to calculated volumes and functional indices. Results Of 3,215 subjects with measurable images, 552 (17%) had a calculated LV shortening fraction (SF) Conclusions Although blinded measurements of LV size show good reproducibility in healthy children, subsequently calculated LV functional indices reveal significant variability despite qualitatively normal systolic function. This suggests that, in clinical practice, abnormal SF/EF values may result in repeat measures of LV size to match the subjective assessment of function. Abnormal LV functional indices were more prevalent in younger, smaller children.