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Objective: To assess the epicardial fat thickness (EFT) and modified myocardial performance index (Mod-MPI) measurements in fetuses at pregnant women with preterm prelabor rupture of membranes (pPROM) and compare them to healthy pregnant women's fetuses., Methods: Forty patients who presented to our clinic at 24-36 + 6 gestational weeks and were diagnosed with pPROM were included in the patient group. During the same period, 40 healthy pregnant women at similar gestational weeks were randomly selected as the control group., Results: The pPROM and control groups were similar in terms of demographics. In the pPROM group, EFT, Mod-MPI, and isovolumetric contraction(ICT) and relaxation times(IRT) were significantly higher and ejection time (ET) was significantly lower compared to the control group. In addition, Mod-MPI z -scores, IRT z -scores, ICT z -scores were significantly higher and ET z -scores was significantly lower in the pPROM. According to the ROC analysis, the optimal cutoff value of EFT was calculated as 1.55 mm, with 68% sensitivity and 71% specificity (AUC: 0.718, 95% CI: 0.550-0.786, p  = .018) for predicting NICU requirement and the optimal cutoff value of EFT was calculated as 1.55 mm with 72% sensitivity and 73% specificity (AUC: 0.726, 95% CI: 0.556-0.896, p  = .015) for predicting medication use in the pPROM group., Conclusion: This study revealed differences in the EFT and Mod-MPI measurements of the fetuses of pregnant women with pPROM. Considering that EFT is an important energy source for the myocardium, as well as an endocrine structure in which inflammatory and anti-inflammatory markers are secreted, it is recommended to be evaluated in inflammatory conditions such as pPROM.

Background: Ejection time (ET), acceleration time (AT) and time between left ventricular and aortic systolic pressure peaks (T-LVAo) might be of diagnostic and prognostic use in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI)., Aim: We aimed to assess the diagnostic value and prognostic impact of invasively measured ET, AT, and T-LVAo in patients undergoing TAVI., Methods: A total of 1274 patients received invasive measurement of ET, AT and T-LVAo prior to TAVI. Anatomic AS severity was assessed by CT-derived aortic valve calcification density (AVC d ). Impact on all-cause mortality was retrospectively analyzed., Results: In multivariable linear regression, T-LVAo showed the strongest correlation with AVC d . No prognostic impact of T-LVAo was found according to uni- and multivariable analyses. In contrast, using an individual C-statistic derived cutoff (C D ), patients with ET or AT ≥ C D showed lower mortality rates compared to patients with ET or AT < C D (1-year mortality: ET ≥ vs. < C D : 15.01vs. 33.1%, AT ≥ vs < C D 16.3 vs. 26.5%, p < 0.001). Moreover, multivariable analysis identified ET ≥ C D (HR 0.61 [95% CI 0.43-0.87; p < 0.007]) to be associated with beneficial outcome after TAVI, independent from clinical risk factors and echocardiography-derived parameters., Conclusion: Among the studied hemodynamic parameters T-LVAo provides the highest diagnostic value, whereas ET is an outcome predictor beyond clinical risk factors and echocardiographic parameters in AS patients following TAVI. These parameters could be of considerable use in diagnostic evaluation and risk assessment of patients scheduled for TAVI. T-LVAo (yellow): defined as time between left ventricular and aortic systolic pressure peaks. ET (green): Ejection Time defined as time from the start to flow end. AT (orange): Acceleration time defined as time from the start to the peak flow. AOP: aortic pressure, AVC: aortic valve calcification, CI: confidence interval, HGAS: high-gradient aortic stenosis, LGAS: low-gradient aortic stenosis, LVP: left ventricular pressure, SD: standard deviation., (© 2023. The Author(s).)

Objective: The primary aim of this study was to determine whether pulmonary artery acceleration time (AT) to ejection time (ET) ratio (PATET) was altered in fetuses of mothers with intrahepatic cholestasis of pregnancy (IHCP). The secondary aim was to investigate the association between fetal pulmonary artery Doppler parameters with neonatal outcomes in pregnancies complicated by IHCP., Material and Methods: This prospective case control study was conducted in a tertiary perinatal-neonatal center. A total of 18 fetuses whose mothers’ pregnancies were complicated by IHCP were included as the study group and a total of 37 fetuses of mothers with healthy pregnancies were selected as controls. Fetal pulmonary artery Doppler parameters (AT; ET; AT/ET ratio) were assessed and neonatal outcomes were evaluated., Results: Mean pulmonary artery AT, ET and PATET were significantly different between the groups (p=0.001, p=0.024 and p=0.003, respectively). The mean PATET value in the IHCP group was 0.217±0.029 while in the control group it was 0.180±0.020. While PATET values were correlated with gestational age at birth, respiratory distress and need for neonatal intensive care admission were not correlated with PATET., Conclusion: Higher values of PATET may be a useful biomarker of fetal lung damage, secondary to IHCP.

Aims: The assessment of aortic stenosis (AS) severity is still challenging, especially in abnormal hemodynamic conditions. Left ventricular ejection time (LVET) has been historically related to AS severity, but it also depends on heart rate (HR) and systolic function. Our aim was to verify if correcting LVET (LVET index, LVETI) by its determinants is helpful for the assessment of AS severity, irrespective of hemodynamic conditions. Methods and results: We retrospectively studied 152 patients with AS and 378 patients with heart failure and no-AS. At multivariate analysis, LVET (assessed with pulsed-wave Doppler) showed a strong correlation with stroke volume index (SVI) (Beta 0.354; p < 0.001), HR (−0.385; p < 0.001), AS grade (Beta 0.301; p < 0.001) and, less significantly, ejection fraction (LVEF) (Beta 0.108; p = 0.001). AS grade was confirmed to be a major determinant of LVET, irrespective of forward flow (assessed by SVI and transvalvular flow rate) and LVEF (above and below 50%). A regression equation was derived to index LVET (LVETI) to HR and SVI. By using this formula, LVETI detected severe AS more accurately (AUC 0.812, p < 0.001) than LVET alone (AUC 0.755, p for difference = 0.005). Similar results were observed in patients with abnormal flow status. As an exploratory finding, we observed that the highest tertile of LVETI was associated with a higher rate of aortic valve interventions during follow-up. Conclusions: LVETI correlates with AS severity better than uncorrected LVET, independently from hemodynamic conditions, and may help to discriminate severe AS. This finding needs confirmation in larger prospective multicenter studies.

Objectives: Fetal cardiac function can be evaluated using a variety of parameters. Among these, cardiac cycle time-related parameters, such as filling time fraction (FTF) and ejection time fraction (ETF), are promising but rarely studied. We aimed to report the feasibility and reproducibility of fetal FTF and ETF measurements using pulsed-wave Doppler, to provide reference ranges for fetal FTF and ETF, after evaluating their relationship with heart rate (HR), gestational age (GA) and estimated fetal weight (EFW), and to evaluate their potential clinical utility in selected fetal conditions., Methods: This study included a low-risk prospective cohort of singleton pregnancies and a high-risk population of fetuses with severe twin-twin transfusion syndrome (TTTS), aortic stenosis (AoS) or aortic coarctation (CoA), from 18 to 41 weeks' gestation. Left ventricular (LV) and right ventricular inflow and outflow pulsed-wave Doppler signals were analyzed, using valve clicks as landmarks. FTF was calculated as: (filling time/cycle time) × 100. ETF was calculated as: (ejection time/cycle time) × 100. Intraclass correlation coefficients (ICC) were used to evaluate the intra- and interobserver reproducibility of FTF and ETF measurements in low-risk fetuses. The relationships of FTF and ETF with HR, GA and EFW were evaluated using multivariate regression analysis. Reference ranges for FTF and ETF were then constructed using the low-risk population. Z-scores of FTF and ETF in the high-risk fetuses were calculated and analyzed., Results: In total, 602 low-risk singleton pregnancies and 54 high-risk fetuses (nine pairs of monochorionic twins with severe TTTS, 16 fetuses with AoS and 20 fetuses with CoA) were included. Adequate Doppler traces for FTF and ETF could be obtained in 95% of low-risk cases. Intraobserver reproducibility was good to excellent (ICC, 0.831-0.905) and interobserver reproducibility was good (ICC, 0.801-0.837) for measurements of all timing parameters analyzed. Multivariate analysis of FTF and ETF in relation to HR, GA and EFW in low-risk fetuses identified HR as the only variable predictive of FTF, while ETF was dependent on both HR and GA. FTF increased with decreasing HR in low-risk fetuses, while ETF showed the opposite behavior, decreasing with decreasing HR. Most recipient twins with severe TTTS showed reduced FTF and preserved ETF. AoS was associated with decreased FTF and increased ETF in the LV, with seemingly different patterns associated with univentricular vs biventricular postnatal outcome. The majority of fetuses with CoA had FTF and ETF within the normal range in both ventricles., Conclusions: Measurement of FTF and ETF using pulsed-wave Doppler is feasible and reproducible in the fetus. The presented reference ranges account for associations of FTF with HR and of ETF with HR and GA. These time fractions are potentially useful for clinical monitoring of cardiac function in severe TTTS, AoS and other fetal conditions overloading the heart. © 2020 International Society of Ultrasound in Obstetrics and Gynecology., (© 2020 International Society of Ultrasound in Obstetrics and Gynecology.)

Radial applanation tonometry is a well-established method for clinical hemodynamic assessment and is also becoming popular in wrist-worn fitness trackers. The time difference between the foot and the dicrotic notch of the arterial pressure waveform is a well-accepted approximation for the left ventricular ejection time (ET). However, several clinical studies have shown that ET measured from the radial pressure waveform deviates from that measured centrally. In this work, we consider the systolic wave and the dicrotic wave as two independent traveling waves and hypothesize that their wave speed difference leads to the intersite differences of measured ET (ΔET). Accordingly, we derived a mathematical dicrotic wave decomposition model and identified the most influential factors on ΔET via global sensitivity analysis. In our clinical validation on a heterogeneous cohort ( N = 5,742) from the Framingham Heart Study (FHS), the local sensitivity analysis results resembled the sensitivity variation patterns of ΔET from model simulations. A regression analysis on FHS data, using morphological features of radial pressure waveforms to estimate the carotid ET, produced a root mean square error of 3.76 ms and R 2 Based on a new understanding of pressure wave propagation, we propose a novel dicrotic wave decomposition model considering the dicrotic wave as an independent traveling component. The proposed model can explain the mechanism underlying the intersite discrepancies in ejection time measurement from arterial waveforms and then, in principle, enhance the accuracy of both classical physics-based as well as more contemporary artificial intelligence-based pulse wave analysis methods in clinical and wearable radial blood pressure monitoring applications.NEW & NOTEWORTHY Based on a new understanding of pressure wave propagation, we propose a novel dicrotic wave decomposition model considering the dicrotic wave as an independent traveling component. The proposed model can explain the mechanism underlying the intersite discrepancies in ejection time measurement from arterial waveforms and then, in principle, enhance the accuracy of both classical physics-based as well as more contemporary artificial intelligence-based pulse wave analysis methods in clinical and wearable radial blood pressure monitoring applications.

Introduction: Aortic stenosis (AS) is considered severe when the aortic valve area (AVA) is < 1.0 cm 2 and the mean aortic valve gradient (mAVG) exceeds 40 mm Hg. Since many patients with AVA < 1.0 cm 2 do not manifest an mAVG > 40 mm Hg, we sought to determine the AVA at which mAVG tends to exceed 40 mm Hg in a sample of subjects with varied transvalvular flow rates., Material and Methods: Our echocardiography database was queried for subjects with native valve AS. We selected 200 subjects with an AVA < 1.0 cm 2 . The sample was selected to include subjects with varied mean systolic flow (MSF) rates. Linear regression was performed to determine the relationship between MSF and mAVG. Since this relationship varied by AVA, the regression was stratified by AVA (critical < 0.6 cm 2 , severe 0.6-0.79 cm 2 , moderately severe 0.8-0.99 cm 2 )., Results: The study sample was 79 ±12 years old and was 60% female. The MSF rate at which mAVG tended to exceed 40 mm Hg was 120 ml/s for critical AVA, 183 ml/s for severe AVA and 257 ml/s for moderately severe AVA. Those with moderately severe AVA rarely (8%) had an mAVG > 40 mm Hg at a wide range of MSF. In contrast, those with severe AVA typically (75%) had mAVG > 40 mm Hg when MSF was normal (> 200 ml/s). Those with critical AVA frequently (44%) had mAVG > 40 mm Hg, even when MSF was reduced., Conclusions: Subjects with AVA of 0.8 and 0.9 cm 2 rarely had mAVG > 40 mm Hg, even when the transvalvular flow rate was normal. Using current guidelines, it is not clear if such cases should be classified as severe., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2021 Termedia & Banach.)

Objectives: Aortic acceleration time (AAT) and the ratio of AAT to ejection time (AAT/ET) are relatively new echocardiographic measures of the severity of aortic stenosis (AS). This study investigated the utility of transesophageal echocardiography (TEE) measurements of AAT and AAT/ET to predict the severity of AS under intraoperative conditions., Design: Retrospective diagnostic accuracy study., Setting: St. Vincent's Hospital, Melbourne, Australia, from July 2007 to February 2017., Participants: The study comprised 199 patients who underwent aortic valve replacement (AVR) and whose aortic valves were evaluated with spectral Doppler analysis in both preoperative transthoracic echocardiography (TTE) and intraoperative TEE studies fewer than three months apart. Exclusion criteria included AVR for only aortic regurgitation, AVR of prosthetic aortic valves, and known left ventricular outflow tract obstruction., Measurements and Main Results: Standard echocardiography assessment of AS and the AAT and AAT/ET measurements was performed using preoperative TTE and intraoperative TEE. The intraoperative AAT and AAT/ET were increased significantly in patients with both high- and low-gradient severe AS compared with patients without severe AS (p < 0.01). Comparing preoperative TTE and intraoperative TEE measurements showed that the AAT was significantly prolonged during general anesthesia (mean difference 9.67 msec [95% confidence interval -13.54 to -5.81]), whereas the AAT/ET was preserved (mean difference -0.0018 [95% confidence interval -0.013 to 0.0091]). An intraoperative TEE cutoff of 109 msec for AAT and 0.35 for AAT/ET had a 74% and 67% sensitivity and 72% and 78% specificity, respectively, to differentiate severe from non-severe AS., Conclusions: The AAT and AAT/ET may be useful adjuncts for the intraoperative measurement of AS. The agreement between intraoperative TEE and preoperative TTE was better with AAT/ET compared with AAT alone., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the time of ureteral ejection of intravenous sodium fluorescein in the assessment of ureteral patency in patients undergoing total laparoscopic hysterectomy (TLH)., Material and Methods: Fifty-four women undergoing TLH were studied in a public teaching hospital in Culiacan, Sinaloa, Mexico. They underwent cystoscopic evaluation of ureteral patency after intravenous administration of 100 mg of sodium fluorescein. The present study analyzed the time elapsed in minutes from the intravenous administration of fluorescein to the outflow of stained urine by one or both ureteral meatus, the degree of urine staining, and the impact of body mass index (BMI) (BMI; normal, overweight, and obesity) on ejection time., Results: The overall average time elapsed to visualize the ejection of fluorescein through at least one ureteral meatus was 7.5 minutes [95% confidence interval (CI): 6.3-8.7]. There were no significant differences in the time of ureteral ejection of fluorescein taking BMI into account (p=0.579), with a mean time for normal BMI of 8.1 minutes (95% CI: 5.1-11.2), for overweight of 7.0 minutes (95% CI: 5.5-8.5), and for obesity of 7.8 minutes (95% CI: 5.3-10.3)., Conclusion: Intravenously administered 10% sodium fluorescein dye is rapidly eliminated and strongly stains urine, which makes it useful for identifying ureteral patency during cystoscopy after TLH. Fluorescein excretion is not affected by patient BMI.

Each stroke volume ejected by the heart is distributed along the arterial system as a pressure waveform. How far the front of the pressure waveform travels within the arterial system depends both on the pulse wave velocity (PWV) and the ejection time (ET). We tested the hypothesis that ET and PWV are coupled together, in order to produce a pulse wave travel distance (PWTD = PWV × ET) which would match the distance from the heart to the most distant site in the arterial system. The study was conducted in 11 healthy volunteers. We recorded lead II of the ECG along with pulse plethysmography at ear, finger and toe. The ET at the ear and pulse arrival time to each peripheral site were extracted. We then calculated PWV followed by PWTD for each location. Taken into account the individual subject variability PWTD Toe in the supine position was 153 cm (95% CI 146-160 cm). It was not different from arterial pathway distance from the heart to the toe (D Toe 153 cm). The PWTD Finger and PWTD Ear were longer than the distance from the heart to the finger and ear irrespective of body position. ET Ear and PWV Toe appear to be coupled in healthy subjects to produce a PWTD that is roughly equivalent to the arterial pathway distance to the toe. We propose that PWTD should be evaluated further to test its potential as a noninvasive parameter of ventricular-arterial coupling in subjects with cardiovascular diseases.

Elevated blood pressure (BP) is a major risk factor for atherosclerosis. As the studies concerning vascular alterations in pediatric patients are rare, we aimed to study the relationship between hypertension and arterial stiffness in adolescence by novel method independent from BP during examination. Twenty nonobese adolescent boys (16.5 ± 0.4 years) with newly diagnosed essential hypertension, 20 adolescent boys (16.7 ± 0.4 years) with newly diagnosed white-coat hypertension, and 20 healthy controls matched to age and body mass index were examined. Cardio-ankle vascular index (CAVI), brachial-ankle pulse wave velocity (baPWV), pre-ejection period (PEP), and ejection time (ET) were evaluated. CAVI was significantly increased in essential hypertension patients compared with controls (p < 0.05) with no significant difference in white-coat hypertension patients. Significantly higher baPWV was found in essential and white-coat hypertension patients compared with controls (both p < 0.001). White-coat hypertension patients showed significantly shortened PEP and ET compared with controls (p < 0.01 and p < 0.001, respectively) and essential hypertension patients (both p < 0.05). For the first time, the arterial stiffness in adolescents with newly diagnosed essential and white-coat hypertension was studied using BP-independent index CAVI combined with conventional baPWV. Our study revealed significantly increased CAVI in adolescents with newly diagnosed essential hypertension compared with controls. Our findings could help to understand hypertension-atherosclerosis interaction.

Purpose: The pre-ejection period-derived myocardial performance index measured from tissue Doppler echocardiography (PEPa-derived MPI) was reported to be associated with left ventricular systolic and diastolic function in atrial fibrillation (AF). However, its relationship with cardiovascular outcomes in AF has never been evaluated. This study sought to examine the ability of PEPa-derived MPI in predicting adverse cardiovascular events in AF patients., Methods: In 196 persistent AF patients, we performed comprehensive echocardiography with measurement of PEPa-derived MPI using index beat method. The index beat was defined as the beat following the nearly equal preceding (RR1) and pre-preceding (RR2) intervals. The cycle length of index beat and RR1 and RR2 must be >500ms and the difference between RR1 and RR2 must be <60ms. Cardiovascular events were defined as cardiovascular death, nonfatal stroke, and hospitalization for heart failure., Results: In the multivariate analysis, chronic heart failure and increased ratio of transmitral E-wave velocity to early diastolic mitral annulus velocity (E/Ea) and PEPa-derived MPI (per 0.1 increase, hazard ratio, 1.104; 95% confidence interval, 1.032-1.182, p=0.004) were associated with increased cardiovascular events. The addition of PEPa-derived MPI to a Cox model containing chronic heart failure, systolic blood pressure, age, diabetes, prior stroke, left ventricular ejection fraction, and E/Ea provided an additional benefit in prediction of adverse cardiovascular events (p=0.015)., Conclusions: In AF patients, the PEPa-derived MPI was a useful predictor of adverse cardiovascular events and could offer an additional prognostic benefit over conventional clinical and echocardiographic parameters., (Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Tissue Doppler imaging (TDI) may be useful in identifying subjects at higher risk among patients with chronic heart failure (CHF). The clinical role of new developed TDI parameters, however, still needs to be documented., Methods: A total of 113 consecutive patients with CHF enrolled in the Daunia heart failure registry underwent echocardiography assessment and were followed prospectively for 234 ± 262 days. Conventional echocardiography and TDI parameters were calculated. We also calculated peak myocardial acceleration during isovolumic relaxation time (pIVA[r]) derived from TDI (pIVV(r)/AT)., Results: Subjects readmitted for worsening HF were characterized by lower levels of pIVA(r) (0.8 ± 0.3 vs. 1.3 ± 0.5 m/s(2) , P < 0.001). pIVA(r) levels predicted the incidence of readmission for worsening HF during follow-up (HR 0.78, 95% confidence interval 0.64-0.96, P < 0.05), even after multivariable analysis. The assessment of pIVA(r) in addition to left ventricular ejection fraction (LVEF) and E/E' provided additional prognostic value (Log Rank P < 0.05). The presence of abnormal pIVA(r), LVEF, and E/E' levels identified subjects with a higher risk of hospitalization for worsening dyspnea during follow-up than those with 2 abnormal marker levels or 0-1 (Log Rank P < 0.05)., Conclusions: Peak myocardial acceleration during isovolumic relaxation time may represent an independent adjunctive tool for the risk stratification of patients with CHF., (© 2013, Wiley Periodicals, Inc.)

Background: Presence of right ventricular (RV) infarction imposes a higher risk of adverse events in inferior wall myocardial infarction (IWMI). In this study, we attempted to correlate various indices of RV function assessed by echocardiography with presence of a proximal right coronary artery (RCA) stenosis in patients with first episode of acute IWMI., Methods: In a prospective study, patients with first episode of acute IWMI underwent echocardiographic assessment within 24 h of symptom onset and indices of RV function viz. RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI) and tissue Doppler velocities from RV free wall were measured. Patients who underwent coronary angiogram (CAG) within one month and they were classified into group 1 and group 2 based on the presence or absence, respectively, of a significant proximal RCA stenosis., Results: There were 90 patients with first episode of IWMI of which 67 patients underwent CAG. There was significant difference between group 1 (n = 26) and group 2 (n = 41) in TAPSE (13.5 ± 1.3 vs 21.3 ± 1.7, p < 0.001), MPI by tissue Doppler (0.87 ± 0.1 vs 0.55 ± 0.2, p < 0.001) and in tissue Doppler systolic velocity from RV free wall (S' 9.8 ± 1.1 vs 15.0 ± 1.5, p < 0.001). There was a good interobserver correlation for TAPSE, MPI by TDI, and S' velocity. TAPSE ≤ 16 (sensitivity 93%, specificity 100%), MPI-TDI ≥ 0.69 (sensitivity 94.7%, specificity 93.5%), S ≤ 12.3 (sensitivity 90.3%, specificity 94.3%) were useful in predicting presence of proximal RCA stenosis., Conclusion: RV function indices like TAPSE, MPI-TDI and S' velocity are useful in predicting proximal RCA stenosis in first episode of acute IWMI., (Copyright © 2013 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)