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Background: The predictive value of left ventricular (LV) global longitudinal strain (GLS) to predict outcomes in different left ventricular ejection fraction (LVEF) cohorts is not well known. We aimed to assess the role of LV GLS predicting outcomes in HF patients by LVEF. Methods: In the Multicenter Automatic Defibrillator Implantation Trial Cardiac Resynchronization Therapy (MADIT‐CRT), we studied 1077 patients (59%) with 2D speckle tracking data available, 437 patients with LVEF > 30% and 640 with LVEF ≤ 30%. Baseline LV GLS was stratified in tertiles in both LVEF subgroups. The primary endpoint was ventricular tachycardia/fibrillation (VT/VF) or death; the secondary endpoint was heart failure (HF) or death. Results: In patients with LVEF ≤ 30%, a higher tertile GLS (T3, less contractility) was associated with a higher rate of VT/VF/death (P < 0.001), with similar association in patients with LVEF > 30% (P = 0.057). In patients with LVEF ≤ 30%, a higher tertile GLS was also associated with a higher rate of HF/death. In multivariable models, LV GLS predicted VT/VF or death in the LVEF ≤ 30% subgroup [T1 vs. T2/3 HR = 1.67 (1.16–2.38), P = 0.005], but not in those with LVEF > 30% [T1 vs. T2.3 HR = 1.32 (0.86–2.04), P = 0.21]. LV GLS predicted HF/death in the LVEF ≤ 30% subgroup [T1 vs T2/3 HR = 2.00 (1.30–3.13), P = 0.002], but not in in those with LVEF > 30%. Conclusions: In this MADIT‐CRT sub‐study, LV GLS identified patients at higher risk of VT/VF, HF/death risk independently of conventional clinical parameters in patients with LVEF ≤ 30%, but not in patients with LVEF > 30%. [ABSTRACT FROM AUTHOR]

Background: Assessment of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) plays a key role in the diagnosis of cardiac amyloidosis (CA). However, manual measurements are time consuming and prone to variability. We aimed to assess whether fully automated artificial intelligence (AI) calculation of LVEF and GLS provide similar estimates and can identify abnormalities in agreement with conventional manual methods, in patients with pre‐clinical and clinical CA. Methods: We identified 51 patients (age 80 ± 10 years, 53% male) with confirmed CA according to guidelines, who underwent echocardiography before and/or at the time of CA diagnosis (median (IQR) time between observations 3.87 (1.93, 5.44 years). LVEF and GLS were quantified from the apical 2‐ and 4‐chamber views using both manual and fully automated methods (EchoGo Core 2.0, Ultromics). Inter‐technique agreement was assessed using linear regression and Bland‐Altman analyses and two‐way ANOVA. The diagnostic accuracy and time for detecting abnormalities (defined as LVEF ≤ 50% and GLS ≥ −15.1%, respectively) using AI was assessed by comparisons to manual measurements as a reference. Results: There were no significant differences in manual and automated LVEF and GLS values in either pre‐CA (p =.791 and p =.105, respectively) or at diagnosis (p =.463 and p =.722). The two methods showed strong correlation on both the pre‐CA (r =.78 and r =.83) and CA echoes (r =.74 and r =.80) for LVEF and GLS, respectively. The sensitivity and specificity of AI‐derived indices for detecting abnormal LVEF were 83% and 86%, respectively, in the pre‐CA echo and 70% and 79% at CA diagnosis. The sensitivity and specificity of AI‐derived indices for detecting abnormal GLS was 82% and 86% in the pre‐CA echo and 100% and 67% at the time of CA diagnosis. There was no significant difference in the relationship between LVEF (p =.99) and GLS (p =.19) and time to abnormality between the two methods. Conclusion: Fully automated AI‐calculated LVEF and GLS are comparable to manual measurements in patients pre‐CA and at the time of CA diagnosis. The widespread implementation of automated LVEF and GLS may allow for more rapid assessment in different disease states with comparable accuracy and reproducibility to manual methods. [ABSTRACT FROM AUTHOR]

Background: Late gadolinium enhancement (LGE) imaging in patients with implantable cardioverter-defibrillators (ICD) is limited by device-related artifacts (DRA). The use of wideband (WB) LGE protocols improves LGE images, but their efficacy with different ICD types is not well known.Purpose: To assess the effects of WB LGE imaging on DRA in different non-MR conditional ICD subtypes.Study Type: Retrospective.Population: A total of 113 patients undergoing cardiac magnetic resonance imaging with three ICD subtypes: transvenous (TV-ICD, N = 48), cardiac-resynchronization therapy device (CRT-D, N = 48), and subcutaneous (S-ICD, N = 17).Field Strength/sequence: 5 T scanner, standard LGE, and WB LGE imaging with a phase-sensitive inversion recovery segmented gradient echo sequence.Assessment: DRA burden was defined as the number of artifact-positive short-axis LGE slices as percentage of the total number of short-axis slices covering the left ventricle from based to apex, and was determined for WB and standard LGE studies for each patient. Additionally, artifact area on each slice was quantified.Statistical Tests: Shapiro-Wilks, Kruskal-Wallis analysis of variance, Dunn tests with Bonferroni correction, and Mann-Whitney U-test.Results: In patients with TV-ICD, DRA burden was significantly reduced and nearly eliminated with WB LGE compared to standard LGE imaging (median [interquartile range]: 0 [0-7]% vs. 18 [0-50]%, P < 0.05), but WB imaging had less of an impact on DRA in the CRT-D (8 [0-23]% vs. 16 [0-45]%, p = 0.12) and S-ICD (60 [15-71]% vs. 67 [50-92]%, P = 0.09) patients. Residual DRA was significantly greater (P < 0.05) for S-ICD compared to other device types with WB LGE imaging, despite the generators of all three ICD types having similar proximity to the heart. The area of S-ICD associated DRA was smaller with WB LGE (P < 0.001) than with standard LGE imaging and the artifacts had different characteristics (dark signal void instead of a bright hyperenhancement artifact).Data Conclusion: Although WB LGE imaging reduced the burden of DRA caused by S-ICD, the residual artifact was greater than that observed with TV-ICD and CRT-D devices. Further developments are needed to better resolve S-ICD artifacts.Level Of Evidence: 1 TECHNICAL EFFICACY: STAGE: 5. [ABSTRACT FROM AUTHOR]

Background: Despite routine use of echocardiographic parameters to evaluate the severity of cardiac amyloidosis (CA), this methodology has not been well validated. We developed a histopathologic schema for quantifying CA burden and evaluated its relationship with clinical outcomes. Additionally, echocardiographic parameters were tested as potential noninvasive indices of CA burden. Methods: We retrospectively studied 59 patients with CA (17 light chain, 42 transthyretin) who underwent endomyocardial biopsies. Light microscopy with staining was used to categorize CA burden as mild‐to‐moderate (<50%) or high (≥50%). Kaplan‐Meier survival analysis was performed for the two groups. In 34 patients with good‐quality echocardiograms, we measured left ventricular volumes, ejection fraction (EF), interventricular septal thickness (IVSt), posterior wall thickness (PWt), LV mass, lateral e′‐velocity, and global longitudinal strain (GLS). These parameters were compared between the two groups. Results: Thirty‐five patients had mild‐to‐moderate and 24 severe amyloid burden. Kaplan‐Meier curves demonstrated a trend toward worse mortality with high CA burden, which was more common and associated with higher mortality specifically in transthyretin‐type patients. Echocardiography‐derived IVSt, PWt, and LV mass were directly related to CA burden, while LV EF, e′‐velocity, and GLS magnitude were inversely related to CA burden. Conclusions: Our findings provided a signal that CA burden is a clinically important entity with potentially valuable prognostic information. Echocardiographic parameters of LV anatomy and function correlate with histopathologic burden of CA, which is inversely related to survival. Further studies are needed to determine whether these parameters could be used as imaging biomarkers of treatment‐related changes in CA burden. [ABSTRACT FROM AUTHOR]

Background: Although 3D echocardiography (3DE) circumvents many limitations of 2D echocardiography by allowing direct measurements of left ventricular (LV) mass, it is seldom used in clinical practice due to time‐consuming analysis. A recently developed 3DE machine learning (ML) approach allows automated determination of LV mass. We aimed to evaluate the accuracy of this new approach by comparing it to cardiac magnetic resonance (CMR) reference and to conventional 3DE volumetric analysis. Methods: We prospectively studied 23 patients who underwent 3DE (Philips EPIQ) and CMR imaging on the same day. Single‐beat wide‐angle 3D datasets of the left ventricle were acquired. LV mass was quantified using the new automated software (Philips HeartModel) with manual corrections when necessary and using conventional volumetric analysis (TomTec). CMR analysis was performed by manual slice‐by‐slice tracing of LV endo‐ and epicardial boundaries. Reproducibility of the ML approach was assessed using repeated measurements and quantified by intra‐class correlation (ICC) and coefficients of variation (CoV). Results: Automated LV mass measurements were feasible in 20 patients (87%). The results were similar to CMR‐derived values (Bland‐Altman bias 5 g, limits of agreement ±37 g) and also to the conventional 3DE analysis (bias 7 g, ±27 g). Processing time was considerably shorter: 1.02 ± 0.24 minutes (CMR: 2.20 ± 0.13 minutes; TomTec: 2.36 ± 0.09 minutes), although manual corrections were performed in most patients. Repeated measurements showed high reproducibility: ICC = 0.99; CoV = 4 ± 5%. Conclusions: 3D Echocardiography analysis of LV mass using novel ML‐based algorithm is feasible, fast, and accurate and may thus facilitate the incorporation of 3DE measurements of LV mass into clinical practice. [ABSTRACT FROM AUTHOR]

Background: Quantitative 3D assessment of the aortic root may improve planning and success of aortic valve (AV)‐sparing operations. Aims: To use 3D transesophageal echocardiography (TEE) to assess the effect of chronic aortic dilatation on aortic root shape and aortic regurgitation (AR) severity and to examine the effects of AV‐sparing operations. Methods and Results: To determine the changes with chronic aortic dilatation, we studied 48 patients, 23 with aortic dilatation (Group 1 ≤ mild AR, n = 13; Group 2 ≥ moderate AR, n = 10) and 25 Controls. To determine the changes in AV‐sparing operations, a subgroup of 15 patients were examined pre‐ and post surgery. 3D‐TEE images were analyzed using multiplanar reconstruction (QLAB, Philips, Philips Medical Systems, Andover, MA, USA) to obtain aortic root areas, diameters, and lengths. We also calculated a novel parameter called total coaptation surface area (TCoapSA), which sums the contact surface area of all the AV cusps. Compared to Controls, Groups 1 and 2 had significantly larger aortic root areas, inter‐commissural distances, and cusp heights. Compared to Group 1 and Controls, Group 2 had significantly smaller TCoapSA when adjusted for aortic annular area (P = 0.001) with shorter coaptation height (P < 0.001). In patients undergoing AV‐sparing surgery, TCoapSA was significantly larger post surgery (P = 0.001) with greater coaptation height (P < 0.001) and smaller inter‐commissural distances (P < 0.001). Conclusions: The aortic valve is a dynamic structure that remodels in response to aortic dilatation. Successful valve‐sparing surgery corrects these changes. Quantitative modeling of the aortic valve and root could potentially improve the repair to the individual patients and modify outcomes. [ABSTRACT FROM AUTHOR]

Preservation of native left ventricular (LV) function in patients supported with LV assist device (LVAD) may be beneficial to attain optimal hemodynamics and enhance potential recovery. Currently, LVAD speed optimization is based on hemodynamic parameters, without considering residual native LV function. We hypothesized that alternatively, LV rotational mechanics can be quantified by 3D echocardiography (3DE), and may help preserve native LV function while optimizing LVAD speed. The goal of this study was to test the feasibility of quantifying the effects of LVAD implantation on LV rotational mechanics and to determine whether conventional speed optimization maximally preserves native LV function. We studied 55 patients with LVADs, who underwent 3DE imaging and quantitative analysis of LV twist. Thirty patients were studied before and after LVAD implantation. The remaining 25 patients were studied during hemodynamic ramp studies. The pump speed at which LV twist was maximal was compared with the hemodynamics‐based optimal speed. LV twist decreased following LVAD implantation from 4.2 ± 2.7 to 2.3 ± 1.9° (P < 0.01), reflecting the constricting effects on native function. With lower pump speeds, no significant changes were noted in LV twist, which peaked at a higher speed. In 11/25 (44%) patients, the conventional hemodynamic/2DE methodology and 3DE assessment of maximal residual function did not indicate the same optimal conditions, suggesting that a higher pump speed would have better preserved native function. In conclusion, quantitative 3DE analysis of LV rotational mechanics provides information, which together with hemodynamics may help select optimal pump speed, while maximally preserving native LV function. [ABSTRACT FROM AUTHOR]

Good‐quality chest compressions improve outcomes in cardiac arrest. While manual chest compressions are suboptimal in this regard, the LUCAS device has been shown to improve the effectiveness of chest compressions during cardiopulmonary resuscitation (CPR). The complication rate associated with mechanical CPR, however, has not been adequately studied. Limited evidence suggests no difference in internal injury between manual and mechanical CPR. We report the case of a patient on anticoagulation who developed a mediastinal hematoma post mechanical CPR and on whom subtle findings on initial echocardiography could have alerted the clinician to this complication early during the clinical course. This case further suggests that there may be special populations of patients in whom we may need to be more vigilant in the use of mechanical CPR. [ABSTRACT FROM AUTHOR]

Purpose To examine a novel non-convex star ordering/shutter for reducing the number of breath-holds in cardiac three-dimensional (3D) T1 Mapping MRI with multiple breath-holds. Methods A novel ordering, Non-Convex Star (NCS) was designed to acquire 3D volumes in a modified look-locker inversion recovery (MOLLI) T1 mapping sequence to provide more spatial resolution and coverage in fewer breath-holds. The proposed 3D-MOLLI approach using NCS was first validated in two phantoms using artifact power (AP) measurement against the fully sampled phantom. This was followed by an in vivo study in seven swine, in which the T1 values of the left ventricular (LV) myocardium divided into the American Heart Association (AHA) 16-segment model was compared against the reference multislice two-dimensional (2D) clinical reference and 3D volume without NCS breath-hold reduction. Results NCS breath-hold reduction yielded less AP compared with the matched SENSE accelerated phantom volume ( P < 0.0005), and was shown to be optimal at 25% fewer breath-holds. Calculated T1 values from 3D in vivo volumes with/without NCS were comparable in all AHA segments ( P = NS), whereas 3D-NCS yielded significantly higher T1 values than 2D at midslice of the LV myocardium in each AHA segment ( P < 0.05). Conclusion We successfully demonstrate the feasibility of the NCS approach for a 3D T1 mapping acquisition requiring fewer breath-holds. Magn Reson Med 77:2215-2224, 2017. © 2016 International Society for Magnetic Resonance in Medicine [ABSTRACT FROM AUTHOR]

Background With the increasing use of transcatheter aortic valve replacement ( TAVR) in patients with aortic stenosis (AS), computed tomography ( CT) remains the standard for annulus sizing. However, 3D transesophageal echocardiography ( TEE) has been an alternative in patients with contraindications to CT. We sought to (1) test the feasibility, accuracy, and reproducibility of prototype 3DTEE analysis software (Philips) for aortic annular measurements and (2) compare the new approach to the existing echocardiographic techniques. Methods We prospectively studied 52 patients who underwent gated contrast CT, procedural 3 DTEE, and TAVR. 3 DTEE images were analyzed using novel semi-automated software designed for 3D measurements of the aortic root, which uses multiplanar reconstruction, similar to CT analysis. Aortic annulus measurements included area, perimeter, and diameter calculations from these measurements. The results were compared to CT-derived values. Additionally, 3D echocardiographic measurements (3D planimetry and mitral valve analysis software adapted for the aortic valve) were also compared to the CT reference values. Results 3 DTEE image quality was sufficient in 90% of patients for aortic annulus measurements using the new software, which were in good agreement with CT ( r-values: .89-.91) and small (<4%) inter-modality nonsignificant biases. Repeated measurements showed <10% measurements variability. The new 3D analysis was the more accurate and reproducible of the existing echocardiographic techniques. Conclusions Novel semi-automated 3 DTEE analysis software can accurately measure aortic annulus in patients with severe AS undergoing TAVR, in better agreement with CT than the existing methodology. Accordingly, intra-procedural TEE could potentially replace CT in patients where CT carries significant risk. [ABSTRACT FROM AUTHOR]

Background Although left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) are recommended by the current echocardiographic chamber quantification guidelines, these measurements are not performed routinely. Because EF measurements rely on manual tracing of LV boundaries, and are subject to inter-reader variability and experience dependence, we hypothesized that semiautomated GLS measurements using speckle tracking would be more reproducible and less experience-dependent. Methods Images from 30 patients were analyzed to obtain biplane EF using manual tracing. GLS was measured in three long-axis views using EchoInsight software (Epsilon Imaging) that automatically detects LV endocardial boundary, which is edited manually as necessary and is then automatically tracked throughout the cardiac cycle. All measurements were performed by an expert echocardiographer and three first-year cardiology fellows. Results Semiautomated GLS analysis showed excellent correlation ( r=.98) and small bias (−1.0±13% of measured value) between the experienced and less experienced readers, superior to EF ( r=.91, bias 7.3±16%). Also, in repeated measurements, GLS showed higher intra-class correlation (ICC=.98) than EF (ICC=.89). Additionally, GLS analysis required ~1 minute per patient, while biplane EF measurements took twice as long. Conclusions Semiautomated GLS measurements are fast, less experience-dependent, and more reproducible than conventional EF measurements. This is probably because, irrespective of experience, the readers' choice of boundary position varies less when asked to refine the automated detection than to draw borders without initial clues. This technique may facilitate the workflow of a busy laboratory and make a step forward toward incorporating quantitative analysis into everyday echocardiography practice. [ABSTRACT FROM AUTHOR]

Background Cardiac infiltration is an important cause of death in sarcoidosis. Transthoracic echocardiography ( TTE) has limited sensitivity for the detection of cardiac sarcoidosis ( CS). Late gadolinium enhancement ( LGE) cardiovascular magnetic resonance ( CMR) is used to diagnose CS but has limitations of cost and availability. We sought to determine whether TTE-derived global longitudinal strain ( GLS) may be used to identify individuals with CS, despite preserved left ventricular ejection fraction ( LVEF), and whether abnormal GLS is associated with major cardiovascular events ( MCE). Methods We studied 31 patients with biopsy-proven extra-cardiac sarcoidosis, LVEF>50% and LGE on CMR ( CS+ group), and 31 patients without LGE ( CS− group), matched by age, sex, and severity of lung disease. GLS was measured using vendor-independent speckle tracking software. Parameters of left and right ventricular systolic and diastolic function were also studied. Receiver-operating characteristic curves were used to identify GLS cutoff for CS detection, and Kaplan-Meier plots to determine the ability of GLS to predict MCE. Results LGE was associated with reduced GLS (−19.6±1.9% in CS− vs −14.7±2.4% in CS+, P<.01) and with reduced E/A ratio (1.1±0.3 vs 0.9±0.3, respectively, P =.01). No differences were noted in other TTE parameters. GLS magnitude inversely correlated with LGE burden ( r=−.59). GLS cutoff of −17% showed sensitivity and specificity 94% for detecting CS. Patients who experienced MCE had worse GLS than those who did not (−13.4±0.9% vs −17.7±0.4%, P=.0003). Conclusions CS is associated with significantly reduced GLS in the presence of preserved LVEF. GLS measurements may become part of the TTE study performed to screen for CS. [ABSTRACT FROM AUTHOR]

Background 'McConnell's sign' (Mc CS), described as hypo- or akinesis of the right ventricular ( RV) free wall with preservation of the apex, is associated with acute pulmonary embolism ( aPE). However, the sensitivity of Mc CS for the detection of aPE is limited. We sought to evaluate in patients with Mc CS, whether echocardiographic parameters of global and regional RV function could differentiate between patients with and without aPE. Methods We reviewed echocardiograms of 81 patients with Mc CS, who underwent CT or V/Q studies for suspected PE, and 40 normal controls ( NL). Echocardiograms were analyzed to measure pulmonary artery systolic pressure ( PASP), tricuspid regurgitation ( TR) by vena contracta width, conventional indices of RV function, and speckle tracking-derived longitudinal free wall strain. ROC analysis was performed to evaluate the diagnostic accuracy of these parameters for diagnosis of aPE. Results Fifty-five of eighty-one (68%) had PE (Mc CS + PE), while 26 of 81 (32%) did not (Mc CS − PE). Compared to NL, global and segmental RV strain were lower in patients with Mc CS, contrary to the notion of normal apical function. In Mc CS + PE, compared to Mc CS − PE: (1) PASP, fractional area change and TR were significantly lower; (2) strain magnitude was significantly lower globally and in basal and apical segments. Individual parameters had similar diagnostic accuracy by ROC analysis, which further improved by combining parameters. In Mc CS − PE, 69% of patients had pulmonary hypertension ( PH). Conclusions Mc CS and aPE are not synonymous. RV free wall strain may aid in differential diagnosis of patients with Mc CS evaluated for aPE. Specifically, Mc CS should prompt an inquiry for evidence of PH, which would indicate that aPE is less likely. [ABSTRACT FROM AUTHOR]

The left ventricle ( LV) is affected in 20-25% of patients with sarcoidosis and its involvement is associated with morbidity and mortality. However, effects of sarcoidosis on the right ventricle ( RV) are not well documented. Our aims were to investigate the prevalence of RV dysfunction in patients with sarcoidosis and determine whether it is predominantly associated with direct cardiac involvement, severity of lung disease, or pulmonary hypertension ( PH). We identified 50 patients with biopsy-proven extra-cardiac sarcoidosis and preserved LV function, who underwent echocardiography, pulmonary function ( PF) testing, and cardiovascular magnetic resonance. RV function was quantified by free wall longitudinal strain. Tricuspid valve Doppler and estimated right atrial pressure were used to estimate systolic pulmonary artery pressure. Myocardial late gadolinium enhancement was considered diagnostic for cardiac sarcoidosis and assumed to involve both ventricles. Of the 50 patients, 28 (56%) had RV dysfunction, 4 with poorly defined PF status. Of the remaining 24 patients, 16 (67%) had lung disease, 8 (33%) had PH, and 10 (42%) had LV involvement. Ten patients had greater than one of these findings, and 4 had all 3. In contrast, in 4/24 patients (17%), RV dysfunction could not be explained by these mechanisms, despite severely reduced RV strain. In conclusion, RV dysfunction is common in patients with sarcoidosis and is usually associated with either direct LV involvement, lung disease, or PH, but may occur in the absence of these mechanisms, suggesting the possibility of isolated RV involvement and underscoring the need for imaging protocols that would include RV strain analysis. [ABSTRACT FROM AUTHOR]

Background Right ventricular ( RV) strain is a potentially useful prognostic marker in patients with pulmonary arterial hypertension ( PAH). However, published reports regarding the accuracy of two-dimensional echocardiography (2 DE)-derived RV strain against an independent reference in this patient population are limited. The aims of this study were: (1) to study the relationship between 2 DE RV longitudinal strain and cardiovascular magnetic resonance ( CMR)-derived RV ejection fraction ( RVEF) in patients with PAH; (2) to compare 2 DE-derived and CMR-derived RV longitudinal strain in these patients; and (3) to determine the reproducibility of these measurements. Methods Thirty patients with PAH underwent 2 DE and CMR imaging within a 2-hour time period. 2 DE RV longitudinal strain was measured from a focused RV apical four-chamber view using speckle tracking software. CMR RV longitudinal strain was measured from short-axis slices acquired using fast-strain-encoded sequence. Global peak systolic RV longitudinal strain was calculated for both 2 DE and CMR. Results RV longitudinal strain using 2 DE software correlated well with CMR-derived RVEF (R = 0.69, P = 0.0006). There was moderate agreement when comparing 2 DE to CMR RV longitudinal strain (R = 0.74, P = 0.0002; bias −1%, limits of agreement −9 to 7%). Inter-observer variability and intra-observer variability for RV longitudinal strain were lower for 2 DE than CMR. Conclusions RV longitudinal strain by 2 DE provides a good alternative for CMR-derived RVEF in patients with PAH. The moderate agreement in strain measurements between 2 DE and CMR suggests that further software improvements are needed before these measurements can be used interchangeably in clinical practice. [ABSTRACT FROM AUTHOR]

An elderly man with dyspnea and syncope was found to have severe aortic stenosis ( AS) by the continuity equation, despite a transaortic gradient that was only moderately elevated, in the setting of severe left ventricular dysfunction. The transaortic gradient increased during postextrasystolic beats, suggesting that his that his AS was truly severe; this was confirmed by dobutamine echocardiography. He underwent transcatheter aortic-valve replacement ( TAVR), with subsequent improvement in left ventricular systolic function. The diagnostic and prognostic significance of postextrasystolic potentiation, with associated increase in aortic stenosis gradient, deserves renewed attention in the TAVR era. [ABSTRACT FROM AUTHOR]

Background: Assessment of right ventricular (RV) function is difficult due to the complex shape of this chamber. Tricuspid annular plane systolic excursion (TAPSE) measured with M-mode echocardiography is frequently used as an index of RV function. However, its accuracy may be limited by ultrasound beam misalignment. We hypothesized that two-dimensional (2D) speckle tracking echocardiography (STE) could provide more accurate estimates of RV function. Accordingly, STE was used to quantify tricuspid annular displacement (TAD), from which RV longitudinal shortening fraction (LSF) was calculated. These STE derived indices were compared side-by-side with M-mode TAPSE measurements against cardiac magnetic resonance (CMR) derived RV ejection fraction (EF). Methods: Echocardiography (Philips iE33, four-chamber view) and CMR (Siemens, 1.5 T) were performed on the same day in 63 patients with a wide range of RV EF (23-70% by CMR). TAPSE was measured using M-mode echocardiography. TAD and RV LSF were obtained using STE analysis (QLAB CMQ, Philips). TAPSE, TAD and RV LSF values were compared with RV EF obtained from CMR short axis stacks. Results: STE analysis required <15 seconds and was able to track tricuspid annular motion in all patients as verified visually. Correlation between RV EF and TAD (0.61 free-wall, 0.65 septal) was similar to that with M-mode TAPSE (0.63). However, STE-derived RV LSF showed a higher correlation with CMR EF (r = 0.78). Conclusion: RV LSF measurement by STE is fast and easy to obtain and provides more accurate evaluation of RV EF than the traditional M-mode TAPSE technique, when compared to CMR reference. (Echocardiography 2012;29:19-24) [ABSTRACT FROM AUTHOR]

Aims Late gadolinium enhanced cardiovascular magnetic resonance (LGE-CMR) is a valuable test to detect myocardial damage in patients with sarcoidosis; however, the clinical significance of LGE in sarcoidosis patients with preserved left ventricular ejection fraction (LVEF) is not defined. We aim to characterize the prevalence of LGE, its associated cardiac findings, and its clinical implications in sarcoidosis patients with preserved LVEF. Methods and results One hundred and fifty-two patients with biopsy proven extra-cardiac sarcoidosis, no known cardiac sarcoidosis, and LVEF ≥50% referred for LGE-CMR were included in this observational study. The presence of LGE in the left ventricular myocardium was considered diagnostic for cardiac sarcoidosis. The cohort was divided into two groups based on the presence or absence of LGE. Twenty-nine patients (19%) had LGE involving 11 ± 9% of the left ventricle. The modified Japanese Ministry of Health and Welfare (JMHW) criteria for diagnosing cardiac sarcoidosis only had a sensitivity of 52% and specificity of 83% for identifying myocardial LGE in these patients. Compared with those patients without LGE, those with LGE had a higher heart rate (84 ± 19 vs. 76 ± 18 b.p.m., P= 0.002), greater prevalence of an abnormal electrocardiogram (76 vs. 31%, P< 0.001), diastolic dysfunction (67 vs. 33%, P= 0.05), reduced right ventricular ejection fraction (49 ± 8 vs. 55 ± 6%, P= 0.012), and evidence of non-sustained ventricular tachycardia (33 vs. 6%). Conclusions In patients with sarcoidosis and preserved systolic function, myocardial damage is commonly present and may increase the risk of ventricular tachy-arrhythmias. The JMHW Criteria were neither sensitive nor specific for predicting the presence of myocardial LGE. [ABSTRACT FROM AUTHOR]

Purpose To develop a technique based on image noise distribution for automated endocardial border detection from cardiac magnetic resonance (CMR) images throughout the cardiac cycle, validate it, and test its clinical utility. Materials and Methods Images obtained in 36 patients were analyzed using custom software to obtain left ventricular (LV) volume throughout the cardiac cycle, end-systolic and end-diastolic LV volumes, and ejection fraction (EF). Validation against manually-traced endocardial boundaries included intertechnique comparisons of LV volumes, slice areas, and border positions. Then, the clinical feasibility of the dynamic automated analysis of LV function was tested in 14 patients with normal LV function, 12 patients with systolic dysfunction, and 10 patients with diastolic dysfunction. Results Analysis time for one cardiac cycle was <15 minutes. Intertechnique comparisons resulted in high correlation (r > 0.96), small biases (volumes: -6 mL; EF: 4.6%) and narrow limits of agreement (volumes: 17.6 mL; EF: 9.2%). We found significant intergroup differences in multiple quantitative indices of systolic and diastolic function. Conclusion Fast, automated, dynamic detection of LV endocardial boundaries is feasible and allows accurate quantification of LV size and function, which is potentially clinically useful for objective assessment of systolic and diastolic dysfunction. J. Magn. Reson. Imaging 2009;29:560-568. © 2009 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

Background: Transthoracic echocardiography (TTE) is ordered frequently in patients with suspected pulmonary embolism (PE). Multiple indices have been suggested to play a useful diagnostic role. We sought to determine the relative predictive accuracy of suggested quantitative indices among patients referred for CT scanning for exclusion of PE. Methods: We retrospectively identified 67 consecutive patients who underwent CT for the exclusion of PE, and had a TTE within 48 hours of CT. Echo indices suggested to play a role in the diagnosis of PE were measured RV/LV area ratio, RV/LV end diastolic dimension ratio, the “McConnell” sign, interventricular septal shift (“D-sign”), Pulmonary artery diameter, tricuspid regurgitation velocity, and “60/60 sign” (TR velocity < 3.9 m/sec plus pulmonary artery acceleration time < 60 msec). Results: CT confirmed PE in 41 (61%). Mean age was 58 (18–92). Forty-five were female. Subjects with PE were younger, and more likely to be tachycardic and require ICU admission. Of the echocardiographic indices, RV/LV EDD ratio > 0.7 was the most accurate predictor (sensitivity 66%, specificity 77%). The McConnell sign was the most specific (96%), however, with poor sensitivity (16%). Mean TR velocities did not differ between those with and without PE (270 ± 74 vs. 294 ± 83, P = 0.25). Conclusions: RV/LV EDD ratio > 0.7 has good accuracy for the diagnosis of acute PE. RV/LV area ratio > 0.7 and McConnell sign are specific but not sensitive indicators of acute pulmonary embolism. The presence of these findings should prompt further diagnostic testing for PE. [ABSTRACT FROM AUTHOR]

To determine if the normal gestational changes in mechanical properties of the arterial system are altered in pre-eclampsia. Prospective controlled observational study. University urban tertiary medical centre. Eleven pre-eclamptics and 10 chronic hypertensives with superimposed pre-eclampsia were compared with 14 normotensive gravidas experiencing preterm labour, all receiving MgSO4. Two additional control groups were studied as well: (A) nine normal pregnant women receiving neither magnesium nor epidural, for baseline comparisons; and (B) eight normotensive gravidas receiving epidural anaesthesia. Two-dimensional targeted M-mode echocardiograms and continuous wave Doppler velocity were used to obtain instantaneous pressure and flow data. Total vascular resistance (TVR) quantified the steady component of systemic arterial load; pulsatile arterial load was characterised by global arterial compliance (AC), aortic input impedance spectrum (Z1) and characteristic impedance (Z0). TVR, AC, Z1, Z0. Controls, pre-eclamptics and chronic hypertensives with superimposed pre-eclampsia, respectively: TVR index 1328 [299], 1973 [609]*, 2428 [562]*,# dyn second cm−5 m2; AC area index 1.69 [0.46], 1.19 [0.46]*, 0.93 [0.38]* mL mmHg−1 m−2; Z0 index 253.2 [61.3], 327.0 [135.1], 307.5 [130.9] dyn second cm−5 m2; and Z1 index 184.2 [56.5], 283.6 [81.6]*, 357.1 [119.5]* dyn second cm−5 m2 (* P< 0.05 vs control;# P< 0.05 vs pre-eclampsia). Normal gravidas (in secondary controls group A) had decreased mean systolic and diastolic blood pressures, and increased AC and cardiac indices, compared with women receiving magnesium tocolysis, verifying the need for these primary controls. No differences were noted between normotensive gravidas receiving epidural anaesthesia (secondary controls group B) and the non-anesthetised controls (group A), eliminating epidural as a confounder. The normal gestational changes in systemic arterial mechanical properties are significantly altered in pre-eclampsia and these alterations are more marked with superimposed hypertensive disease. [ABSTRACT FROM AUTHOR]

Background: Transthoracic Doppler echocardiography (TTDE) assessment of coronary flow velocity reserve (CFVR) has been validated in Asian and European centers. This methodology has not gained acceptability in the United States due to the bias that coronary flow velocity (CFV) by TTDE might be difficult in an obese population with relatively poor acoustic windows. Methods: Baseline CFV in the left anterior descending coronary artery (LAD) by TTDE was obtained in 67 nonselected American patients. A subset of 38/67 received adenosine infusion for measuring CFVR of the LAD. Purpose: The aim of this study was twofold: (1) to determine the feasibility of measuring CFV and CFVR in the LAD by TTDE in a relatively obese American population, and (2) to compare CFV and CFVR values in this population with those previously obtained in a group of Japanese patients. Results: The mean body mass index (BMI) of the American population (28± 6 kg/m2, range: 18–46 kg/m2) was significantly higher than that of the Japanese group (23± 4 kg/m2, range: 15–37 kg/m2). Twenty-five American patients were classified as obese (BMI>30kg/m2). Baseline CFV was obtained in 60/67 patients (feasibility: 90%) with a 10% need for intravenous contrast agent to enhance the delineation of the CFV envelope. The success rate in recording CFVR in American patients (92%) was nearly identical to that of a Japanese group (99%). The time-averaged peak diastolic coronary flow velocity increased from 15.6± 5.5 cm/sec at baseline to 47.1± 17.9 cm/sec during adenosine infusion, and CFVR was calculated to be 3.22± 1.15 (range: 0.94–5.69). Intraobserver and interobserver variability for the CFV recording was 4.7 and 6.2%, respectively. Conclusions: These results suggest that the noninvasive measurement of CFV and CFVR of the LAD is feasible even in a relatively obese American population. Furthermore, the success rates for recording CFV and CFVR are similar to those measured in a Japanese population. This methodology has the potential to provide useful physiological information on the coronary circulation in American patients.(ECHOCARDIOGRAPHY, Volume 22, March 2005) [ABSTRACT FROM AUTHOR]

Introduces a compact disc featuring clinical experiences of physicians from different countries using real-time three-dimensional echocardiography.

Atypical cardiac myxomas are a rare occurrence and may present with a variety of clinical manifestations depending on the morphology and location. We present three cases of myxomas located atypically on the left atrial appendage ridge, chordae of the mitral valve, and right atrium. Echocardiography plays a prominent role in the diagnosis and follow-up of these patients. (ECHOCARDIOGRAPHY, Volume 21, January 2004) [ABSTRACT FROM AUTHOR]

Over the last three decades, the continuing development of transesophageal echocardiography (TEE) has represented a major advance in our ability to visualize cardiovascular structures with ultrasound. TEE serves as a valuable complement to transthoracic echocardiography (TTE) by allowing: images to be obtained with less attenuation from structures such as the lung, muscle, bone, and soft tissue; high resolution visualization of structures not well seen by TTE, such as left atrial appendage, descending thoracic aorta, and prosthetic heart valves; and assessment of hemodynamics and flow disorders in greater detail. This article provides a brief overview of current as well as emerging clinical applications of transesophageal echocardiography. (ECHOCARDIOGRAPHY, Volume 20, November 2003) [ABSTRACT FROM AUTHOR]

This article describes the obstacles to stress echocardiographic interpretation, and reviews the techniques currently available that offer a more objective approach to stress wall motion analysis than the conventional visual methodology. These techniques include Doppler-based methods, such as myocardial Doppler velocity and strain rate imaging, as well as automated border detection techniques, such as acoustic quantification and color kinesis. (ECHOCARDIOGRAPHY, Volume 20, October 2003) [ABSTRACT FROM AUTHOR]

Endocardial visualization is essential for accurate interpretation of regional wall thickening abnormalities, which constitute the diagnostic hallmark of coronary artery disease, and for reproducible assessment of left ventricular (LV) ejection fraction. Unfortunately, in many cardiac patients, poor image quality does not allow consistent visualization, let alone automated detection, of the endocardial boundary in all segments throughout the cardiac cycle. Continuing efforts directed towards improving endocardial visualization made by both echocardiographic imaging equipment manufacturers and researchers have recently produced new objective, quantitative approaches for the assessment of global and regional LV function. Although these developments have not been integrated into routine clinical practice, they may have a positive impact on endocardial visualization and, thus, eventually improve the ability to accurately and objectively evaluate LV performance. In this review, we discuss some of the latest developments in the use of contrast for the evaluation of LV function. (ECHOCARDIOGRAPHY, Volume 20, October 2003) [ABSTRACT FROM AUTHOR]

Acoustic quantification (AQ) and color kinesis (CK) are techniques that involve automated detection and tracking of endocardial borders. These methods are useful for the evaluation of global and regional left ventricular (LV) systolic function and more recently have been applied to evaluating LV diastolic performance. Assessment of diastolic dysfunction in hypertensive heart disease is a relevant clinical issue in which these techniques have proven useful. The diastolic portion of left atrium and LV AQ area waveforms are frequently abnormal in patients with left ventricular hypertrophy (LVH). Left ventricular AQ curves consistently demonstrate reduced rapid filling fraction (RFF) and peak rapid filling rate (PRFR), elevated atrial filling fraction (AFF), peak atrial filling rate (PAFR), and reductions in the ratio PRFR/PAFR. Acoustic quantification complements traditional Doppler echocardiographic evaluation of global diastolic function. Many patients with significant LVH and normal Doppler diastolic parameters can be identified as having diastolic dysfunction with AQ. In addition, CK has allowed the evaluation of regional diastolic performance in hypertensive patients. Regional filling curves obtained from CK have demonstrated that endocardial diastolic motion is commonly delayed and heterogeneous in patients with LVH. (ECHOCARDIOGRAPHY, Volume 20, October 2003) [ABSTRACT FROM AUTHOR]

Three-dimensional echocardiography has multiple advantages over two-dimensional echocardiography, such as accurate left ventricular quantification and improved spatial relationships. However, clinical use of three-dimensional echocardiography has been impeded by tedious and time-consuming methods for data acquisition and post-processing. A newly developed matrix array probe, which allows real-time three-dimensional imaging with instantaneous on-line volume-rendered reconstruction, direct manipulation of thresholding, and cut planes on the ultrasound unit may overcome the aforementioned limitations. This report will review current methods of three-dimensional data acquisition, emphasizing the real-time methods and clinical applications of the new matrix array probe. (ECHOCARDIOGRAPHY, Volume 20, October 2003) [ABSTRACT FROM AUTHOR]

Physical examination skills have been declining over the past several decades while technology has made diagnostic testing increasingly sophisticated. For patients with cardiovascular disease, the best approach to bedside diagnosis would be one that combines both physical examination and ready access to technology at the time of the patient encounter. Most cardiac testing is not performed at the bedside due to equipment size and time limitations for these tests. Small hand-carried echocardiographic devices are now available for rapid bedside examination. These devices compare well to full-featured systems when used in cardiology outpatient settings and in hospitalized patients who are not critically ill. Compared with physical examination by board certified cardiologists, these devices decrease diagnostic error. Early use of hand-carried echocardiographic devices after physical examination has been demonstrated to impact patient triage and treatment as well as uncover otherwise undetected cardiac disease. The degree of training required for responsible use of these devices is as yet unclear. However, organized training sessions have resulted in modest agreement with standard echocardiography and point-of-care echocardiography performed by expert echocardiographers. It is conceivable that the hand-carried echocardiographic devices will be used in medical school curriculum to enhance medical student education in the future. (ECHOCARDIOGRAPHY, Volume 20, July 2003). [ABSTRACT FROM AUTHOR]

Background: Prior studies have reconstructed mitral regurgitant flow in three dimensions displaying gray scale renditions of the jets, which were difficult to differentiate from surrounding cardiac structures. Recently, a color-coded display of three-dimensional (3D) regurgitant flow has been developed. However, this display was unable to integrate cardiac anatomy, thereby losing spatial information, which made it difficult to determine the jet origin and its spatial trajectory. To overcome this limitation, an improved method of 3D color reconstruction of regurgitant jets obtained from color flow Doppler using a transesophageal approach was developed to allow the combined display of both color flow and gray scale information. Objectives: To demonstrate the feasibility of 3D reconstruction of regurgitant mitral flow jets using an improved method of color encoding digital data acquired by transesophageal echocardiography (TEE). Methods: We studied 46 patients undergoing a clinically indicated TEE study. All subjects had mitral regurgitation detected on a previous transthoracic study. Atrial fibrillation or poor image quality were not used as exclusion criteria. The 3D study was performed using a commercial ultrasound imaging system with a TEE probe (Sonos 5500, Agilent Technologies). A rotational mode of acquisition was used to collect two-dimensional (2D) color flow images at 3-degree intervals over 180 degrees. Images were processed off line using the Echo-View Software (TomTec Imaging Systems). Volume-rendered 3D color flow jets were displayed along with gray scale information of the adjacent cardiac structures. Results: Mitral regurgitant flow, displayed in left atrial and two longitudinal orientations, was successfully reconstructed in all patients. The time for acquisition, post-processing, and rendering ranged between 10 and 15 minutes. There were 28 centrally directed jets and 15 eccentric lesions. Eight patients in the study had periprosthetic mitral... [ABSTRACT FROM AUTHOR]

The article offers information on a Continuing Medical Education (CME) activity regarding acute pulmonary embolism's (PTE) echocardiographic diagnosis. The CME activity aims to know the implications of McConnell's sign on echocardiography and discover the application of right ventricular strain analysis in acute PTE diagnosis.

The article presents a case study which illustrates the unusual echocardiographic findings of bioprosthetic mitral valve thrombosis in a patient with a thrombotic predisposition caused by homocystenemia. It includes the medical history of the patient and the findings of the study.