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Objective: Hemodynamically significant patent ductus arteriosus (hsPDA) in preterm neonates is associated with end-organ injury including intraventricular hemorrhage. Early treatment may reduce morbidities but may result in overtreatment. This study aimed to examine the association between commonly obtained echocardiographic markers within the first 12 hours of life and eventual treatment of an hsPDA., Study Design: Patients with <32 weeks' gestational age had blinded echocardiograms done within the first 12 hours of life as part of research protocols. Subsequent treatment of the patent ductus arteriosus (PDA) was determined by the clinical team independent of echocardiogram results. t -tests and chi-square tests were done for continuous data and categorical outcomes. A receiver operating curve was created to optimize cutoff values., Results:  Among 199 neonates studied (mean time of echocardiogram 6.7 h after birth), those needing PDA treatment had higher left ventricular output (LVO), right ventricular output (RVO), and superior vena cava (SVC) flow ( p -values 0.007, 0.044, and 0.012, respectively). Cutoffs for predicting PDA treatment were LVO > 204 mL/kg/min (63% sensitivity, 66% specificity), RVO > 221 mL/kg/min or SVC flow > 99 mL/kg/min (sensitivities 70 and 43%, specificities 48 and 73%, respectively)., Conclusion:  Preterm neonates with higher markers of cardiac output in the first 12 hours of birth later required PDA treatment. These data are the first to use standard cardiac output measures in the first 12 hours of life to predict the need for future PDA treatment. Further prospective studies will need to be performed to corroborate these associations between echocardiographic markers and clinical outcomes/morbidities., Key Points: · Early diagnosis of hsPDA may prevent severe morbidity and death.. · There are echocardiographic markers beyond duct size and flow direction that may aid early diagnosis.. · Cardiac output markers within the first 12 hours of life may predict need for treatment of hsPDA.., Competing Interests: None declared., (Thieme. All rights reserved.)

The outcomes of patients with sepsis are influenced by the contractile function of the right ventricle (RV), but the impact of cardiopulmonary interaction in ICU-mortality of sepsis patients remains unclear. This study aims to investigate the ICU-mortality impact of right ventricular-pulmonary artery (RV-PA) coupling in patients with sepsis. We employed echocardiography to assess patients with sepsis within the initial 24 h of their admission to the ICU. RV-PA coupling was evaluated using the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio. A total of 92 subjects were enrolled, with 55 survivors and 37 non-survivors. TAPSE/PASP ratio assessed mortality with an area under the curve (AUC) of 0.766 (95% CI 0.670-0.862) and the optimal cutoff value was 0.495 mm/mmHg. We constructed a nomogram depicting the TAPSE/PASP in conjunction with IL-6 and Lac for the joint prediction of sepsis prognosis, and demonstrated the highest predictive capability (AUC = 0.878, 95% CI 0.809-0.948). In conclusion, the TAPSE/PASP ratio demonstrated prognostic value for ICU mortality in sepsis patients. The nomogram, which combines the TAPSE/PASP, IL-6, and LAC, demonstrated enhanced predictive efficacy for the prognosis of sepsis patients., (© 2024. The Author(s).)

Objective: To summarize echocardiographic characteristics of the anatomy and hemodynamic and clinical outcomes in fetuses with isolated pulmonary stenosis (PS) or pulmonary atresia with intact ventricular septum (PA/IVS)., Methods: This was a single-center retrospective study of fetuses with isolated PS or PA/IVS. Echocardiographic variables and clinical outcomes after delivery were evaluated and compared., Results: Between 2016 and 2021, 115 livebirths with isolated PS or PA/IVS were included. Proportion of fetuses with mild, moderate and critical PS and PA/IVS was 41.7 %, 18.3 %, 26.1 % and 13.9 %. Fetuses with more severe PS had worse anatomic and hemodynamic profiles. Specifically, the cardiothoracic ratio, pulmonary valve (PV) velocity, degree and velocity of tricuspid regurgitation increased as PS severity increased; and the pulmonary artery/aorta ratio, right ventricle/left ventricle long-axis (TV/MV) ratio, tricuspid valve/mitral valve annulus (TV/MV) ratio, and tricuspid valve inflow duration/cardiac cycle ratio decreased as PS severity increased (P <0.001 for all). PV velocity ≥2 m/s predicted PV pressure ≥40 mm Hg after delivery, with an AUC of 0.81; TV/MV ratio combined with RV/LV ratio predicted clinical outcomes, with an AUC of 0.88. Live births with more severe PS had higher mortality rate (mild 0 vs. moderate 0 vs. critical 11 % vs. PA-IVS 36 %) and lower rate of developing bi-ventricles (mild 100 % vs. moderate 95 % vs. critical 89 % vs. PA-IVS 36 %)., Conclusion: Findings of this study help better understand the anatomy and hemodynamic and clinical outcomes in fetuses with isolated PS or PA/IVS, which could have implications for prenatal counseling and prediction of fetal outcome., Competing Interests: Declaration of competing interest All authors declare that they don't have any conflict of interest to disclose., (Copyright © 2024 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)

Superior vena cava is commonly used in neonatal hemodynamics and is suggested to be the best available non-invasive marker for systemic circulation in preterm infants. Inter- and intra-observer variability remain to be an issue. Its association with neonatal outcomes is has not been established. This is a narrative review about this marker, its use, and its potential pitfalls., Objective: This is a narrative review about SVC flow in preterm infants, physiology, techniques of measurement and its potential association with outcomes., Sources: Literature revie mainly PubMED., Summary of the Findings: SVC flow measurement has some limitations and pitfalls., Conclusions: SVC flow association with neonatal outcomes, still needs to be established in further research., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)

International Guidelines consider left ventricular ejection fraction (LVEF) as an important parameter to categorize patients with heart failure (HF) and to define recommended treatments in clinical practice. However, LVEF has some technical and clinical limitations, being derived from geometric assumptions and is unable to evaluate intrinsic myocardial function and LV filling pressure (LVFP). Moreover, it has been shown to fail to predict clinical outcome in patients with end-stage HF. The analysis of LV antegrade flow derived from pulsed-wave Doppler (stroke volume index, stroke distance, cardiac output, and cardiac index) and non-invasive evaluation of LVFP have demonstrated some advantages and prognostic implications in HF patients. Speckle tracking echocardiography (STE) is able to unmask intrinsic myocardial systolic dysfunction in HF patients, particularly in those with LV preserved EF, hence allowing analysis of LV, right ventricular and left atrial (LA) intrinsic myocardial function (global peak atrial LS, (PALS)). Global PALS has been proven a reliable index of LVFP which could fill the gaps "gray zone" in the previous Guidelines algorithm for the assessment of LV diastolic dysfunction and LVFP, being added to the latest European Association of Cardiovascular Imaging Consensus document for the use of multimodality imaging in evaluating HFpEF. The aim of this review is to highlight the importance of the hemodynamics multiparametric approach of assessing myocardial function (from LVFP to stroke volume) in patients with HF, thus overcoming the limitations of LVEF., (© 2024. The Author(s).)

Background: Hemodynamic classification of pulmonary hypertension (PH) has important clinical implications. However, only a few echocardiographic variables have been used to hemodynamically classify PH in dogs., Objective: To evaluate the echocardiographic pulmonary to left atrial ratio index (ePLAR) in dogs with PH., Animals: Forty-six dogs with intermediate to high probability of PH., Methods: Cross-sectional study. Variables were compared between dogs with precapillary PH [PrePH (n = 24)] vs postcapillary PH [PostPH (n = 22)], and with combined PH [CombPH (n = 14)] vs isolated PH [IsoPH (n = 8)] using the t-, Mann-Whitney, Pearson's Chi, or Fisher's exact test. The receiver operating characteristic curve and Youden index were used to identify the optimal ePLAR cutoff value to differentiate among the groups, intraclass correlation coefficients (ICC) were used to determine the reliability of measurements., Results: The mean (SD) ePLAR of the PrePH was higher than that of the PostPH group [0.36 (0.13) vs 0.26 (0.09), respectively; P = .005]. The median (interquartile range) ePLAR of the CombPH was higher than that of the IsoPH subgroup [0.29 (0.24-0.38), vs 0.20 (0.16-0.23), respectively; P = .001]. The best cutoff value of ePLAR for identifying IsoPH was <0.245 [AUC at cutoff point = 0.86; sensitivity (95% confidence interval [CI]) = 0.71 (0.47-0.95); specificity (95% CI) = 1 (0.76-1)]. The ICC analysis indicated a high degree of reliability., Conclusions and Clinical Importance: ePLAR can be considered a valid noninvasive variable to hemodynamically classify PH in dogs with an intermediate to high probability of PH. Assessment of ePLAR can be useful in the therapeutic management of PH in dogs., (© 2024 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals LLC on behalf of American College of Veterinary Internal Medicine.)

Background: In systemic sclerosis (SSc), pulmonary hypertension remains a significant cause of morbidity and mortality. Although conventionally classified as group 1 pulmonary arterial hypertension, systemic sclerosis-related pulmonary hypertension (SSc-PH) is a heterogeneous disease. The contribution of left-sided cardiac disease in SSc-PH remains poorly understood., Research Question: How often does left ventricular (LV) dysfunction occur in SSc among patients undergoing right heart catheterization and how does coexistent LV dysfunction with SSc-PH affect all-cause mortality in this patient population?, Study Design and Methods: We conducted a retrospective, observational study of 165 patients with SSc who underwent both echocardiography and right heart catheterization. LV dysfunction was identified using LV global longitudinal strain (GLS) on speckle-tracking echocardiography based on a defined threshold of > -18%. SSc-PH was defined by a mean pulmonary artery pressure > 20 mmHg., Results: Among patients with SSc who have undergone right heart catheterization, LV dysfunction occurred in 74.2% with SSc-PH and 51.2% without SSc-PH. The median survival of patients with SSc-PH and LV dysfunction was 67.9 (95% CI, 38.3-102.0) months, with a hazard ratio of 12.64 (95% CI, 1.73-92.60) for all-cause mortality when adjusted for age, sex, SSc disease duration, and FVC compared with patients with SSc without pulmonary hypertension with normal LV function., Interpretation: LV dysfunction is common in SSc-PH. Patients with SSc-PH and LV dysfunction by LV GLS have increased all-cause mortality. This suggests that LV GLS may be helpful in identifying underlying LV dysfunction and in risk assessment of patients with SSc-PH., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: J. K. L. receives research support from United Therapeutics and served as a member of the Early Career Editorial Board Member program for the pulmonary vascular section of CHEST. E. S. K. received research support from Bayer, Novartis, Novo Nordisk, and United Therapeutics; received royalties for three topic cards in UpToDate; and is a consultant/advisory board member for Bluebird Bio, Novo Nordisk, Vertex, Pfizer, and CSL Behring for sickle cell disease-related clinical trials (no conflict with the present work). None declared (M. C., M. W., M. A. T., R. S. W., M. P. L., A. M. B., D. M. G.)., (Copyright © 2023 American College of Chest Physicians. All rights reserved.)

Portopulmonary hypertension is an intractable form of pulmonary hypertension. Although liver transplantation is recommended for patients who respond poorly to treatments, the mechanisms by which liver transplantation improves pulmonary hypertension remain unclear. The present study investigated these mechanisms by retrospectively evaluating patients' data. This study retrospectively evaluated echocardiography and catheterization data before and after liver transplantation in 12 patients who underwent liver transplantation from 2001 to 2019. The 12 patients included one male and 11 females, of median age at liver transplantation of 10 years, 2 months. Nine patients underwent liver transplantation for congenital biliary atresia and three for portal vein aplasia or hypoplasia. Mean pulmonary arterial pressure was 44.1 ± 8.1 mmHg at the first cardiac catheter examination, 35.3 ± 7.8 mmHg before liver transplantation, and 29.5 ± 9.3 mmHg 6 months after liver transplantation. Pulmonary artery pressure was reduced by treatments of pulmonary hypertension and by liver transplantation. Pulmonary vascular resistance did not differ before and after liver transplantation, whereas the cardiac index decreased significantly, indicating that the significant reduction in mean pulmonary artery pressure was due to a decrease in cardiac index. Decreased cardiac index was thought to result from improvements in hyperdynamic conditions due to increased (normalized) systemic vascular resistance. Liver transplantation likely suppresses shear stress on pulmonary arteries, preventing further damage by hyper-circulation. A longer-term evaluation is required to determine the effect of improving pulmonary artery remodeling., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Neonatal sepsis remains a leading cause of mortality in neonatal units. Neonatologist-performed echocardiography (NPE) offers the potential for early detection of sepsis-associated cardiovascular dysfunction. This review examines available echocardiographic findings in septic neonates., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed prospective observational, cross-sectional, case control, and cohort studies on septic newborns with echocardiographic assessments from PubMed, Scopus and Embase. Quality assessment employed the Newcastle-Ottawa Scale, with results analyzed descriptively., Results: From an initial pool of 1663 papers, 12 studies met inclusion criteria after relevance screening and eliminating duplicates/excluded studies. The review encompassed 438 septic newborns and 232 controls. Septic neonates exhibited either increased risk of pulmonary hypertension or left ventricular diastolic dysfunction, and a warm shock physiology characterized by higher cardiac outputs., Discussion: The included studies exhibited heterogeneity in sepsis definitions, sepsis severity scores, echocardiographic evaluations, and demographic data of newborns. Limited sample sizes compromised analytical interpretability. Nonetheless, this work establishes a foundation for future high-quality echocardiographic studies., Conclusion: Our review confirms that septic neonates show significant hemodynamic changes that can be identified using NPE. These findings underscore the need for wider NPE use to tailor hemodynamics-based strategies within this population., Impact: 1. Our study emphasizes the value of neonatologist-performed echocardiography (NPE) as a feasible tool for identifying significant hemodynamic changes in septic neonates. 2. Our study underscores the importance of standardized echocardiographic protocols and frequent monitoring of cardiac function in septic neonates. 3. The impact of the study lies in its potential to increase researchers' awareness for the need for more high-quality echocardiographic data in future studies. By promoting wider use of NPE, neonatologists can more accurately assess the hemodynamic status of septic newborns and tailor treatment approaches, potentially improving patient outcomes., (© 2024. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Objective: Targeted neonatal echocardiography (TNE) is a real-time cardiac imaging modality used by a hemodynamics program to aid in diagnosis, treatment, and monitoring of neonatal cardiovascular illness. This study aimed to describe trainees' perspectives on existing hemodynamics education and perceived impacts of TNE and hemodynamics services on their education., Study Design: This was a mixed quantitative and qualitative study that surveyed neonatal-perinatal medicine (NPM) fellow trainees in Canada and the United States, at programs both with and without a hemodynamics service., Results: Ninety-two fellows responded to the survey, of whom 24 (26%) were enrolled in a program with an active hemodynamics service, 64 (70%) were training at a program without a hemodynamics service, and 4 (4%) were unsure. Trainees at centers with a hemodynamics service were more satisfied with their cardiovascular physiology education (91 vs. 69%, p  = 0.040). Twenty-five percent of all trainees felt they do not have sufficient hemodynamics training to prepare them for independent practice. Areas of knowledge gaps were identified. Bedside teaching combined with didactic teaching was identified as useful means of teaching., Conclusion: Most trainees believed that TNE and a hemodynamics service are valuable educational assets. Thoughtful curriculum design for real-time and consolidation learning, with specific emphasis on content gaps, should be considered., Key Points: · NPM Fellows perceive TNE & Neonatal Hemodynamics service as a valuable educational opportunity.. · Incorporation of TNE/Hemodynamics teaching into NPM curriculum can enrich trainee experience.. · Combining bedside and classroom teaching is key to successful cardiovascular training.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Comprehensive assessment of hemodynamic significance of a patent ductus arteriosus (PDA) is a common indication to perform targeted neonatal echocardiography (TNE). Impact of implementation of such an assessment on PDA management decisions remains to be reported. The objective of this study is to compare PDA-related hemodynamic information and PDA treatment decisions before and after introduction of TNE service., Study Design: This was a retrospective cohort study at a tertiary level neonatal intensive care unit in Southwestern Ontario. We investigated two time periods: Epoch-1 (non-TNE 2013-2016) versus Epoch-2 (TNE 2018-2021). We included neonates < 32 weeks with PDA. Data on baseline clinical characteristics, PDA-related echocardiographic parameters, PDA treatment details, and relevant long-term outcomes were collected. Primary outcome was defined as PDA treatment rates and need for multiple courses. Secondary outcomes included availability of PDA hemodynamic data and neonatal mortality/morbidity (PDA-related) RESULTS:  A total of 275 neonates were included. A total of 162 were assessed by conventional echocardiography in Epoch-1, whereas 113 were assessed by TNE in Epoch-2. Baseline clinical characteristics were similar. Epoch-2 had more echocardiographic assessments per patient of 2.7 (±1.8) versus 1.9 (± 1.3), p  < 0.001 in Epoch1. The mean postnatal age at first echocardiographic assessment was higher in Epoch-2 (12.7 days [ ± 14.6]) than in Epoch-1 (7.9 days [ ± 10.4]), p  < 0.001. Comprehensive hemodynamic assessment of PDA-related echocardiographic parameters such as PDA size, shunt pattern, effect on systemic circulation, and pulmonary circulation were higher in Epoch-2. Overall, PDA treatment rates were comparable in the two time periods. The use of multiple courses of treatment was higher in Epoch-1 than in Epoch-2 (47.8 vs. 31.7%, p  = 0.047). In Epoch-1, neonates received PDA treatment earlier than in Epoch-2., Conclusion: With the implementation of the TNE service, increased echocardiographic evaluations per patient were completed with availability of more comprehensive hemodynamic information about PDA. PDA treatment rates were similar in the two epochs, but need for multiple courses were less in TNE era., Key Points: · TNE allows comprehensive hemodynamic assessment of PDA.. · Implementation of dedicated TNE service led to increased use of echocardiography to assess PDA.. · Standardized hemodynamic assessment of PDA may allow improved individualization of treatment need.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: We aimed to determine whether exposure to severe maternal preeclampsia (PE) in very low birth weight (VLBW) infants is associated with hypertrophic cardiac changes and altered hemodynamics., Study Design: Case-control study of VLBW infants born at Los Angeles General Medical Center from May 2015 to August 2023, who had an echocardiogram within the first 7 days of life. Cases were infants exposed to maternal PE and controls were infants not exposed to maternal PE matched by birth weight (BW) 1:1. Laboratory, placental pathology results, hemodynamic data and clinical outcomes were collected and compared between cases and control infants., Results: A total of 43 cases matched by BW with control infants were studied. There were no significant anatomical cardiac changes by echocardiography between cases and control infants. Cases had significantly higher blood pressure within the first 72 hours of life and lower ejection fraction (EF), fractional shortening, and peak systolic flow velocity through their patent ductus arteriosus (PDA) within the first week of life. Cases were more likely to be smaller despite being born at a later gestational age (GA), as well as small for GA with placental weight less than 10th percentile compared to control infants., Conclusion: Our findings indicate that infants born to mothers with PE have higher systemic vascular resistance as evidenced by elevated blood pressure, and lower EF and shortening fraction and higher pulmonary vascular resistance as evidenced by lower peak flow velocity through the PDA. We did not observe hypertrophic cardiac changes in exposed infants. These findings should be considered in clinical decision-making during management of these infants., Key Points: · VLBW infants exposed to severe PE have higher rate of Small for gestational age and smaller placentas.. · VLBW infants exposed to severe PE have higher systemic vascular resistance during transitional period and lower EF and fractional shortening.. · VLBW infants exposed to severe PE have higher pulmonary vascular resistance.., Competing Interests: None declared., (Thieme. All rights reserved.)

Heart failure (HF) is a progressive condition with a clinical picture resulting from reduced cardiac output (CO) and/or elevated left ventricular (LV) filling pressures (LVFP). The original Diamond-Forrester classification, based on haemodynamic data reflecting CO and pulmonary congestion, was introduced to grade severity, manage, and risk stratify advanced HF patients, providing evidence that survival progressively worsened for those classified as warm/dry, cold/dry, warm/wet, and cold/wet. Invasive haemodynamic evaluation in critically ill patients has been replaced by non-invasive haemodynamic phenotype profiling using echocardiography. Decreased CO is not infrequent among ambulatory HF patients with reduced ejection fraction, ranging from 23 to 45%. The Diamond-Forrester classification may be used in combination with the evaluation of natriuretic peptides (NPs) in ambulatory HF patients to pursue the goal of early identification of those at high risk of adverse events and personalise therapy to antagonise neurohormonal systems, reduce congestion, and preserve tissue/renal perfusion. The most benefit of the Guideline-directed medical treatment is to be expected in stable patients with the warm/dry profile, who more often respond with LV reverse remodelling, while more selective individualised treatments guided by echocardiography and NPs are necessary for patients with persisting congestion and/or tissue/renal hypoperfusion (cold/dry, warm/wet, and cold/wet phenotypes) to achieve stabilization and to avoid further neurohormonal activation, as a result of inappropriate use of vasodilating or negative chronotropic drugs, thus pursuing the therapeutic objectives. Therefore, tracking the haemodynamic status over time by clinical, imaging, and laboratory indicators helps implement therapy by individualising drug regimens and interventions according to patients' phenotypes even in an ambulatory setting., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: A high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients., Methods: We included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7-0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables., Results: We included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = -0.59) and LVOT VTI (r = -0.41), as were both systemic vascular resistance index (r = -0.43) and LVEF (r = -0.23)., Conclusion: CICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment., Competing Interests: Declaration of Competing Interest The authors have no relevant conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Swine are frequently used as animal model for cardiovascular research, especially in terms of representativity of human anatomy and physiology. Reference values for the most common species used in research are important for planning and execution of animal testing. Transesophageal echocardiography is the gold standard for intraoperative imaging, but can be technically challenging in swine. Its predecessor, epicardial echocardiography (EE), is a simple and fast intraoperative imaging technique, which allows comprehensive and goal-directed assessment. However, there are few echocardiographic studies describing echocardiographic parameters in juvenile swine, none of them using EE. Therefore, in this study, we provide a comprehensive dataset on multiple geometric and functional echocardiographic parameters, as well as basic hemodynamic parameters in swine using EE., Methods: The data collection was performed during animal testing in ten female swine (German Landrace, 104.4 ± 13.0 kg) before left ventricular assist device implantation. Hemodynamic data was recorded continuously, before and during EE. The herein described echocardiographic measurements were acquired according to a standardized protocol, encompassing apical, left ventricular short axis and long axis as well as epiaortic windows. In total, 50 echocardiographic parameters and 10 hemodynamic parameters were assessed., Results: Epicardial echocardiography was successfully performed in all animals, with a median screening time of 14 min (interquartile range 11-18 min). Referring to left ventricular function, ejection fraction was 51.6 ± 5.9% and 51.2 ± 6.2% using the Teichholz and Simpson methods, respectively. Calculated ventricular mass was 301.1 ± 64.0 g, as the left ventricular end-systolic and end-diastolic diameters were 35.3 ± 2.5 mm and 48.2 ± 3.5 mm, respectively. The mean heart rate was 103 ± 28 bpm, mean arterial pressure was 101 ± 20 mmHg and mean flow at the common carotid artery was 627 ± 203 mL/min., Conclusion: Epicardial echocardiography allows comprehensive assessment of most common echocardiographic parameters. Compared to humans, there are important differences in swine with respect to ventricular mass, size and wall thickness, especially in the right heart. Most hemodynamic parameters were comparable between swine and humans. This data supports study planning, animal and device selection, reinforcing the three R principles in animal research., (© 2024. The Author(s).)

The first week of life is characterized by substantial alterations in hemodynamic conditions. Changes in myocardial contractility will reflect these changes. We aimed to assess right and left ventricular function on the third and seventh days of life in 50 healthy term newborns. To assess myocardial function, we used speckle tracking echocardiography. Pulsed-wave tissue Doppler imaging, M-mode, Doppler and pulsed-wave Doppler were also used to assess ventricular function. We found a significant increase in both right and left longitudinal strain and an increase in systolic and diastolic tissue Doppler velocities, whereas most other parameters remained unchanged. At both time points, the measured parameters were significantly greater for the right ventricle, but the changes with time were similar for both ventricles. We also found an increase in right ventricular outflow tract acceleration time as an indirect sign of decreasing pulmonary vascular resistance and an increase in systolic blood pressure, pointing to increasing systemic vascular resistance. Together with a decreasing proportion of patients with patent ductus arteriosus, the estimated left ventricular cardiac output decreased and right ventricular cardiac output increased but not to a statistically significant degree. In conclusion, the results of our study show how different echocardiographic techniques capture hemodynamic changes and changes in myocardial contractility and compliance. Both longitudinal strain and tissue Doppler imaging parameters seem to offer greater sensitivity in comparison with conventional echocardiographic parameters., (© 2023. The Author(s).)

Background: Diastolic dysfunction in humans is an age-related process with an overrepresentation in women. In rhesus macaques (Macaca mulatta), the incidence and predictors of diastolic dysfunction have yet to be reported., Methods: Data from routine echocardiographic evaluations on clinically healthy rhesus macaques was obtained and used for univariate, bivariate, hypothesis testing, and linear regression statistical analyses interrogating differences and predictors of diastolic function., Results: Rhesus macaques fully recapitulate previously reported human hemodynamic studies. Female monkeys display impaired diastology and are at an increased risk for developing diastolic dysfunction. Age, sex, and proxies of exercise activity are confirmed predictors for measures of diastolic dysfunction, regardless of specific pathogen-free status., Conclusions: Rhesus macaques share common sex- and age-related echocardiographic findings as humans, therefore, serve as a valuable translational nonhuman primate model for future studies of diastolic dysfunction. These findings confirm the importance of sex- and age-matching within future rhesus macaque cardiovascular research., (© 2023 The Authors. Journal of Medical Primatology published by John Wiley & Sons Ltd.)

Introduction: Transthoracic echocardiography is a safe and readily available tool for noninvasive monitoring of Cardiac Output (CO). The use of the suprasternal window situated at the sternal notch can be an alternative approach for estimating blood flow. The present study aimed to compare two methods of CO calculation. We compared the descending aorta Velocity-Time Integral (VTI) measurement from the suprasternal window view with the standard technique to determine CO that uses VTI measurements from the LVOT (Left Ventricular Outflow Tract) view. We also aimed to find out whether after basic training a non-echocardiographer operator can obtain reproducible measurements of VTI using this approach., Methods: In the first part of the study, 26 patients without known cardiovascular diseases were evaluated and VTI data were acquired from the suprasternal window by a non-echocardiographer and an echocardiographer. Next, 17 patients were evaluated by an echocardiographer only and VTI and CO measurements were obtained from suprasternal and apical windows. Data were analyzed using the Bland and Altman method (BA), correlation and regression., Results: We found a strong correlation between measurements obtained by a non-expert and an expert echocardiographer and detected that an inexperienced trainee can acquire VTI measurements from the suprasternal window view. Regarding agreement between CO measurements, data obtained showed a positive correlation and the Bland and Altman analysis presented a total variation of 38.9%., Conclusion: Regarding accuracy, it is likely that TTE (Transthoracic Echocardiogram) measurements of CO from the suprasternal window view are comparable to other minimally invasive techniques currently available. Due to its user-friendliness and low cost, it can be a convenient technique for obtaining perioperative hemodynamic measurements, even by inexperienced operators., (Copyright © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose of Review: The aim of this study was to illustrate the varying roles of echocardiography in all phases of shock ranging from a rapid, diagnostic tool at the bedside, to a tool for monitoring the adequacy and effects of shock treatment and finally for identification of patients suitable for de-escalation of therapy., Recent Findings: Echocardiography has become an indispensable tool for establishing diagnosis in patients with shock. It is also important for assessing the adequacy of treatment such as fluid resuscitation, vasopressors and inotropes by providing integrated information on cardiac contractility and systemic flow conditions, particularly when used in conjunction with other methods of advanced haemodynamic monitoring. Apart from a traditional, diagnostic role, it may be used as an advanced, albeit intermittent, monitoring tool. Examples include the assessment of heart-lung interactions in mechanically ventilated patients, fluid responsiveness, vasopressor adequacy, preload dependence in ventilator-induced pulmonary oedema and indications for and monitoring during extracorporeal life support. Emerging studies also illustrate the role of echocardiography in de-escalation of shock treatment., Summary: This study provides the reader with a structured review on the uses of echocardiography in all phases of shock treatment., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Left ventricular vortex formation optimizes the effective transport of blood volume while minimizing energy loss (EL). Vector flow mapping (VFM)-derived EL patterns have not been described in children, especially in those less than 1 yr of age. A prospective cohort of 66 (0 days-22 yr, 14 patients ≤ 2 mo) cardiovascularly normal children was used to determine left ventricular (LV) vortex number, size (mm 2 ), strength (m 2 /s), and energy loss (mW/m/m 2 ) in systole and diastole and compared across age groups. One early diastolic (ED) vortex at the anterior mitral leaflet and one late diastolic (LD) vortex at the LV outflow tract (LVOT) were seen in all newborns ≤ 2 mo. At >2 mo, two ED vortices and one LD vortex were seen, with 95% of subjects > 2 yr demonstrating this vortex pattern. Peak and average diastolic EL acutely increased in the same 2 mo-2-yr period and then decreased within the adolescent and young adult age groups. Overall, these findings suggest that the growing heart undergoes a transition to adult vortex flow patterns over the first 2 yr of life with a corresponding acute increase in diastolic EL. These findings offer an initial insight into the dynamic changes of LV flow patterns in pediatric patients and can serve to expand our understanding of cardiac efficiency and physiology in children. NEW & NOTEWORTHY This research article demonstrates, for the first time, echocardiographic evidence of a transition in left ventricular vortex patterns from the newborn to the adult period, with an associated change in cardiac efficiency, marked by increased energy loss, during infancy.

This study was aimed at investigating the adaptive changes in myocardial work (MyW) during normal pregnancy. Sequential 2D standard and speckle-tracking echocardiography was performed on 41 pregnant women in each gestational trimester and 4 to 11 mo after delivery. Thirty-eight age-matched, healthy, non-pregnant women served as controls. Four components of MyW-global myocardial work index (GWI), constructive work (GCW), wasted work (GWW) and work efficiency (GWE)-were calculated. GWI began to decline early in the first trimester and remained at a low level until delivery; GCW gradually decreased with gestational progression and reached its lowest level in the third trimester. When compared with the values for non-pregnant women and those postpartum, GWE and GWW remained unchanged in gestation. This study provides normal ranges of MyW during pregnancy. Despite the adapted decrease in GWI and GCW, the myocardium manages to work efficiently in the healthy pregnancy with drastic hemodynamic alternations., Competing Interests: Conflict of interest disclosure The authors declare no competing interests., (Copyright © 2022 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Measurement of cardiac index (CI) is crucial in the hemodynamic assessment of critically ill patients in the intensive care unit (ICU). The most reliable trans-thoracic echocardiography (TTE) technique for CI estimation is the left ventricular outflow tract (LVOT) Doppler method that requires, among other parameters, the LVOT cross-sectional area (CSA) measurement. However, inherent and practical disadvantages, mostly related to the ICU setting, hamper LVOT-CSA assessment. In this study, we aimed to validate a simplified formula, leveraging on LVOT-velocity time integral (VTI) and heart rate (HR) only, for non-invasive estimation of CI in ICU patients., Methods and Results: We prospectively enrolled 50 consecutive patients admitted to our ICU requiring pulmonary artery catheterization (PAC) over a one-year period. For each patient we measured the CI by PAC (CI PAC ) and TTE. The latter was obtained both with the "traditional formula" (traditional CI TTE ), requiring LVOT-CSA assessment, and our new "simplified formula" (simplified CI TTE ). The correlation between the simplified CI TTE and CI PAC was strong (r = 0.81) and resulted significantly greater than the traditional CI TTE and CI PAC correlation (r = 0.70; p < 0.05 for Pearson r coefficients comparison). Both TTE-based CI showed an acceptable agreement (+0.19 ± 0.48 L/min/m 2 for simplified CI TTE and - 0.18 ± 0.58 L/min/m 2 for traditional CI TTE ) with the reference CI PAC ., Conclusion: In this study, we validated a practical approach, leveraging on TTE LVOT-VTI and HR only, for non-invasive estimation of CI in ICU patients., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, reliable, and real-time information on developmental hemodynamics in sick newborns. The comprehensive assessment is based on a multiparametric approach that overcomes the reliability issues of individual measurements, allows for earlier recognition of cardiovascular compromise and promotes enhanced diagnostic precision and timely management. TnECHO-driven research has led to an enhanced understanding of the mechanisms of illness and the development of predictive models to identify at-risk populations. This information may then be used to formulate a diagnostic impression and provide individualized guidance for the selection of cardiovascular therapies. TnECHO is based on the expert consultative model in which a neonatologist, with advanced training in neonatal hemodynamics, performs comprehensive and standardized TnECHO assessments. The distinction from point of care ultrasonography (POCUS), which provides limited and brief one-time assessments, is important. Neonatal hemodynamics training is a 1-year structured program designed to optimize image acquisition, measurement analysis, and hemodynamic knowledge (physiology, pharmacotherapy) to support cardiovascular decision-making. Neonatologists with hemodynamic expertise are trained to recognize deviations from normal anatomy and appropriately refer cases of possible structural abnormalities. We provide an outline of neonatal hemodynamics training, the standardized TnECHO imaging protocol, and an example of representative echo findings in a hemodynamically significant patent ductus arteriosus.

Cardiac reserve is a widely used health indicator and prognostic tool. Although it is well established how to assess cardiac reserve clinically, in preclinical models, it is more challenging lacking standardization. Furthermore, although cardiac reserve incorporates both systolic (i.e., contractile reserve) and diastolic (i.e., relaxation reserve) components of the cardiac cycle, less focus has been placed on diastolic reserve. The aim of our study was to determine which technique (i.e., echocardiography, invasive hemodynamic, and Langendorff) and corresponding parameters can be used to assess the systolic and diastolic reserves in preclinical models. Healthy adult male and female CD-1 mice were administered dobutamine and evaluated by echocardiography and invasive hemodynamic, or Langendorff to establish systolic and diastolic reserves. Here, we show that systolic reserve can be assessed using all techniques in vivo and in vitro. Yet, the current indices available are ineffective at capturing diastolic reserve of healthy mice in vivo. When assessing systolic reserve, sex affects the dose response of several commonly used echocardiography parameters [i.e., fractional shortening (FS), ejection fraction (EF)]. Taken together, this study improves our understanding of how sex impacts the interpretation assessment of cardiac reserve and establishes for the first time that in healthy adult mice, the diastolic reserve cannot be assessed by currently established methods in vivo. NEW & NOTEWORTHY Cardiac reserve is a globally used health indicator and prognostic tool that is used by clinicians and preclinical scientists. In physiology, we have a long-standing appreciation of how to assess systolic reserve but lack insight into sex differences and have no frame of reference for measuring diastolic reserve to certainty across cardiac techniques or the influence of sex. Here, we show that the primary means for assessing diastolic reserve is incorrect. Furthermore, we provided proof and clarity on how to correctly measure systolic and diastolic reserve capacities. We also highlight the imperative of sex differences to the measures of both systolic and diastolic reserves using several techniques (i.e., echocardiography, invasive hemodynamics, and Langendorff) in mice.

Hemodynamic force (HDF) analysis represents a novel approach to quantify intraventricular pressure gradients, responsible for blood flow. A new mathematical model allows the derivation of HDF parameters from routine transthoracic echocardiography, making this tool more accessible for clinical use. HDF analysis is considered the fluid dynamics correlate of deformation imaging and may be even more sensitive to detect mechanical abnormalities. This has the potential to add incremental clinical value, allowing earlier detection of pathology or immediate evaluation of response to treatment. In this article, the theoretical background and physiological patterns of HDF in the left ventricle are provided. In pathological situations, the HDF pattern might alter, which is illustrated with a case of ST segment elevation myocardial infarction and non-ischemic cardiomyopathy with typical left bundle branch block., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aims: Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality., Methods and Results: We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality., Conclusions: Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam., Competing Interests: Conflict of interest: None of the authors has a significant conflict of interest related to this research., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Echocardiography is an imaging method in anaesthesia and intensive care medicine which adds a new dimension to hemodynamic monitoring: the direct visualization of the cardiac function and its disruptions. The review article shows the advantages and limitations of recent transthoracic (TTE) and transesophageal (TEE) echocardiography in the diagnostic course of hemodynamic instability. For TTE and TEE focused examination techniques and sequences are illustrated with regards to their fast applicability to hemodynamic monitoring., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: Transthoracic echocardiography (TTE) is generally recognized as the top choice for detecting myocardial and cardiac cavity lesions. Sonographers mostly focus on myocardium, cardiac cavity and cardiac hemodynamics, whereas the abnormal extra-cardiac lesions are easily remain unrecognized. The aim of this study was to investigate the ultrasonic image features in abnormal extra-cardiac lesions and the value of TTE in the detection of extra-cardiac lesions., Methods: 49 cases of abnormal extra-cardiac lesion detected by TTE from January 2014 to December 2019 were collected, which were confirmed by surgical pathology. The two-dimensional ultrasonic characteristics and the relationships with the cardiac and great vessels were summarized on the basis of multi-view by TTE. All patients were also examined by computed tomography (CT)., Results: In 49 patients with abnormal extra-cardiac lesions, 37 malignant cases and 12 benign cases were included. There were 41 cases (41/49, 86.67%) of mediastinal lesions and 8 cases (8/49, 16.33%) of lung lesions. The maximum diameter ranged from 3.2 cm to 13.66 cm, and the median diameter was about 7.4 cm, among which 29 cases (29/49, 59.18%) were larger than 5 cm. 4 cases (4/49, 8.16%) of cystic anechoic lesions were pericardial cyst. 2 cases (2/49, 4.08%) of cystic-solid echogenic lesions were teratoma. The remaining 43 cases (43/49, 87.76%) presented as solid hypoechoic or heterogeneous masses. 6 cases compressed the heart and 21 cases encroached on the heart and vessels. Diagnosis coincidence rates of TTE and CT were respectively 77.55% and 93.88%, with a statistical difference (p = 0.012)., Conclusion: Although the diagnostic coincidence rate of TTE is slightly lower than that of CT, TTE has certain diagnostic value for extra-cardiac lesions., (© 2022. The Author(s).)

Background: Whether the fundamental hematological and cardiac variables determining cardiorespiratory fitness and their intrinsic relationships are modulated by major constitutional factors, such as sex and age remains unresolved., Methods: Transthoracic echocardiography, central hemodynamics and pulmonary oxygen (O 2 ) uptake were assessed in controlled conditions during submaximal and peak exercise (cycle ergometry) in 85 healthy young (20-44 year) and older (50-77) women and men matched by age-status and moderate-to-vigorous physical activity (MVPA) levels. Main outcomes such as peak left ventricular end-diastolic volume (LVEDV peak ), stroke volume (SV peak ), cardiac output (Q peak ) and O 2 uptake (VO 2peak ), as well as blood volume (BV), BV-LVEDV peak and LVEDV peak -SV peak relationships were determined with established methods., Results: All individuals were non-smokers and non-obese, and MVPA levels were similar between sex and age groups (P ≥ 0.140). BV per kg of body weight did not differ between sexes (P ≥ 0.118), but was reduced with older age in men (P = 0.018). Key cardiac parameters normalized by body size (LVEDV peak , SV peak , Q peak ) were decreased in women compared with men irrespective of age (P ≤ 0.046). Older age per se curtailed Q peak (P ≤ 0.022) due to lower heart rate (P < 0.001). In parallel, VO 2peak was reduced with older age in both sexes (P < 0.001). The analysis of fundamental circulatory relationships revealed that older women require a higher BV for a given LVEDV peak than older men (P = 0.024)., Conclusions: Sex and age interact on the crucial circulatory relationship between total circulating BV and peak cardiac filling, with older women necessitating more BV to fill the exercising heart than age- and physical activity-matched men., (© 2021. The Author(s).)

Objectives: Information on normative reference values for cardiac structures is critical for the accurate application of echocardiography for guiding clinical decision-making. Many studies using transthoracic echocardiography (TTE) have shown that Indians have smaller diameters of various cardiac structures. There are no normative studies for transesophageal echocardiography (TEE). The authors observed dimensions of various cardiac structures in healthy Indian patients under general anesthesia using TEE and compared them with existing guidelines from non-Indian data., Design: The Indian Normative TEE Measurements study was a multicenter, prospective observational study conducted in India., Setting: Operating rooms for noncardiac surgeries in tertiary care-level hospitals., Participants: Adult patients undergoing noncardiac surgery who were free from any cardiac, respiratory, and renal diseases and had no contraindications for TEE., Interventions: After inducing general anesthesia and achieving stable hemodynamic conditions, a comprehensive TEE examination was performed and various measurements were made., Measurements and Main Results: For each of the 83 patients undergoing noncardiac surgery, 39 various measurements for left ventricle, right ventricle, both atria, and all valves were made. This included diameters and functional parameters. They were analyzed in a vendor-neutral software off-line. The absolute values of many of the measurements were higher in men, but when indexed to body surface area (BSA) they were similar in both sexes. The values were lower than most of the Western data but matched previous Indian studies using TTE., Conclusions: The authors present normative values of various echocardiographic parameters using TEE. Because of its variations, it is recommended to use India-specific data to make decisions in Indian patients. It may be prudent to use BSA-indexed values during decision-making., Competing Interests: Conflict of Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aims: We sought to determine whether the Diamond-Forrester classification using non-invasive haemodynamic measurements by 2-D and Doppler echocardiography would predict hospital mortality in cardiac intensive care unit (CICU) patients., Methods and Results: We retrospectively analysed unique patients admitted to the CICU at Mayo Clinic Rochester from 2007 to 2018. Doppler-derived cardiac index (CI) and ratio of mitral valve E velocity to medial mitral annulus e' velocity (E/e' ratio) were used to classify patients into four profiles: Profile I (warm/dry), Profile II (warm/wet), Profile III (cold/dry), and Profile IV (cold/wet). Logistic regression was used to determine predictors of hospital mortality, and Cox proportional-hazards analysis was used to determine predictors of mortality during one year of follow-up. We included 4563 patients with a mean age of 68.3 ± 14.3 years, including 36.2% female patients. The distribution of each profile was as follows: I, 47.4%; II, 36.2%; III, 7.9%; IV, 8.5%. A total of 5.8% patients died during hospitalization, and 18.1% died by 1 year. Patients with either low CI or elevated E/e' ratio had higher in-hospital and 1 year mortality. Patients with elevated E/e' ratio (i.e. Profiles II and IV) had an increased risk of death during hospitalization and at 1 year after multivariate adjustment (adjusted hazard ratio 1.72 and 2.17 for 1 year mortality, respectively, compared with Profile I, P < 0.01)., Conclusions: Simple Doppler echocardiographic assessment can be used to identify haemodynamic profiles defined by the Diamond-Forester classification in patients admitted in CICU. These profiles predict outcomes and may be used to guide therapy in critically ill patients., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

The study objective was to evaluate sedative, hemodynamic, and echocardiographic effects of cats receiving single-dose, oral gabapentin. A prospective, double-blinded, placebo-controlled, crossover study was conducted with 10 client-owned cats. Vital parameters, physical exam, blood pressure, echocardiography, and sedation scoring were performed at each visit within 2 hr of receiving either a placebo or gabapentin capsule. Vital parameters, blood pressure recordings, and echocardiographic measurements were compared between baseline, gabapentin, and placebo; interobserver agreement for sedation scoring and correlation between variables were also evaluated. Seven of 10 cats exhibited mild sedation within 120 min after receiving gabapentin, and no adverse events occurred. Significant differences were detected with two-dimensional fractional shortening (P = .022), left ventricular internal diameter in systole using M-mode (P = .014), and left atrial volume (P < .0001). Interobserver agreement for sedation scoring was near-perfect (κ = 0.84). No significant correlation was found for gabapentin dosage and sedation score. Single-dose oral gabapentin is well tolerated in healthy cats and produces a modest decrease in several echocardiographic parameters of systolic function; however, all affected variables remained within established reference ranges. These results suggest gabapentin may be an appropriate sedative to administer before echocardiography in cats necessitating mild sedation., (© 2021 by American Animal Hospital Association.)

Ultrasound is the imaging modality of choice for the initial evaluation of disorders that involve the abdominal aorta (AA). The diagnostic value of ultrasound resides in its ability to allow assessment of the anatomy and structure of the AA using two- dimensional, three-dimensional, and contrast-enhanced imaging. Moreover, ultrasound permits evaluation of the physiologic and hemodynamic consequences of abnormalities through Doppler interrogation of blood flow, thus enabling the identification and quantification of disorders within the AA and beyond its boundaries. The approach to ultrasound imaging of the AA varies, depending on the purpose of the study and whether it is performed in a radiology or vascular laboratory or in an echocardiography laboratory. The aim of this review is to demonstrate the usefulness of ultrasound imaging for the detection and evaluation of disorders that involve the AA, detail the abnormalities that are detected or further assessed, and outline its value for echocardiographers, sonographers, and radiologists., (Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Brachial systolic blood pressure (BP) is the most commonly used metric for monitoring hypertension. However, recent studies suggest that brachial systolic BP underestimates left ventricle (LV) systolic load in patients with coarctation of aorta (COA). Since brachial systolic BP is used as a surrogate of arterial afterload in clinical practice, it is important to determine how well it correlates with LV remodeling and stiffness in patients with COA as compared to patients with idiopathic hypertension., Methods: This is cross-sectional study of COA patients with hypertension (COA group) and adults with idiopathic hypertension (control group). Both groups were matched 1:1 based on age, sex, BMI and systolic BP. We hypothesized that the COA group will have higher LV systolic and diastolic stiffness, and more advanced left atrial remodeling and pulmonary hypertension. We assessed LV systolic stiffness using end-systolic elastance, and diastolic stiffness using LV stiffness constant and chamber capacitance (LV-end-diastolic volume at an end-diastolic pressure of 20mm Hg) RESULTS: There were 112 patients in each group. Although both groups had similar systolic BP, the COA group had a higher end-systolic elastance (2.37 ± 0.74 vs 2.11 ± 0.54 mm Hg/mL, P= .008), higher LV stiffness constant (6.91 ± 0.81 vs 5.93 ± 0.79, P= .006) and lower LV-end-diastolic volume at an end-diastolic pressure of 20mm Hg (58 ± 9 vs 67 ± 11 mL/m 2 , P< .001). Additionally, the COA group had more advanced left atrial remodeling and higher pulmonary artery pressures which is corroborating evidence of high LV filling pressure., Conclusions: COA patients have more LV stiffness and abnormal hemodynamics compared to non-COA patients with similar systolic BP, suggesting that systolic BP may underestimate LV systolic load in this population. Further studies are required to determine whether the observed LV stiffness and dysfunction translates to more cardiovascular events during follow-up, and whether adopting a stricter systolic BP target in clinical practice or changing threshold for COA intervention will lead to less LV stiffness and better clinical outcomes., (Copyright © 2021. Published by Elsevier Inc.)

Objective: To determine the effects of IV administration of pimobendan on hemodynamic indices and indices of left atrial (LA) longitudinal strain by speckle-tracking echocardiography in healthy dogs., Animals: 6 healthy Beagles., Procedures: After the dogs were anesthetized, the right heart was catheterized and 2-D conventional and speckle-tracking echocardiography were performed before and after IV administration of 0.15 mg of pimobendan/kg. Speckle-tracking echocardiography was performed to assess the 3 LA phasic functions through LA deformation (longitudinal strain and strain rate) and volumetric analyses., Results: Pimobendan significantly increased stroke volume and cardiac output and decreased systemic vascular resistance. Pimobendan significantly improved left ventricular function assessed by the Tei index and LA booster pump function assessed by LA longitudinal strain and change in fractional volume during atrial systole. Indices of LA reservoir and conduit function were unchanged., Conclusions and Clinical Relevance: In healthy dogs, IV administration of pimobendan improved the indices of LA booster pump function but had no effect on the indices of LA reservoir and conduit functions. Further studies are needed to validate whether these results can be extrapolated to dogs with myxomatous mitral valve disease.

This retrospective cohort study aimed to explore the relationship between temporal changes in the cardiac function and peripartum cardiac events in pregnant women with low-risk congenital heart disease.We performed echocardiography at early and late pregnancy and postpartum in 76 pregnant women with low-risk congenital heart disease, and compared echocardiographic parameters between subjects with and without peripartum cardiac events. Median age at delivery was 27 (range, 24-31) years. The ZAHARA and CARPREG II scores suggested that most women were found to be at low-risk for pregnancy. Fifteen subjects had cardiac events that included heart failure in 10, arrhythmia in 4, and pulmonary hypertension in one subject. The left ventricular and atrial volumes significantly increased from early pregnancy toward late pregnancy, and the E/A ratio and global longitudinal strain significantly decreased from early pregnancy toward late pregnancy. The left atrial volume (67 [53-79] versus 45 [35-55] mL, P = 0.002) and plasma brain natriuretic peptide level (58 [36-123] versus 34 [18-48] pg/mL, P = 0.026) at late pregnancy were significantly higher in subjects with cardiac events than in those without cardiac events.An increase in the left atrial volume followed by mild left ventricular diastolic dysfunction is related to peripartum cardiac events in women with congenital heart disease who are at low risk for cardiac events during pregnancy.

Background: The number of high-risk patients undergoing surgery is steadily increasing. In order to maintain and, if necessary, optimize perioperative hemodynamics as well as the oxygen supply to the organs (DO 2 ) in this patient population, a timely assessment of cardiac function and the underlying pathophysiological causes of hemodynamic instability is essential for the anesthesiologist. A variety of hemodynamic monitoring procedures are available for this purpose; however, due to method-immanent limitations they are often not able to directly identify the underlying cause of cardiovascular impairment., Objective: To present a stepwise algorithm for a perioperative echocardiography-based hemodynamic optimization in noncardiac surgery high-risk patients. In this context, echocardiography on demand according to international guidelines can be performed under certain conditions (hemodynamic instability, nonresponse to hemodynamic treatment) as well as in the context of a planned intraoperative procedure, mostly as a transesophageal echocardiography., Methods and Results: Hemodynamically focused echocardiography as a rapidly available bedside method, enables the timely diagnosis and assessment of cardiac filling obstructions, volume status and volume response, right and left heart function, and the function of the heart valves., Conclusion: Integrating all echocardiographic findings in a differentiated assessment of the patient's cardiovascular function enables a (patho)physiologically oriented and individualized hemodynamic treatment., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objectives: To examine differences in maternal cardiovascular indices at 19-23 weeks' gestation between pregnancies that develop gestational diabetes mellitus (GDM) and those without GDM, and to determine whether such cardiovascular changes are the consequence of maternal demographic characteristics and medical history or GDM per se., Methods: This was a prospective observational study in women attending for a routine hospital visit at 19 + 1 to 23 + 3 weeks' gestation. This visit included recording of maternal demographic characteristics and medical history, and maternal echocardiography for assessment of E/A ratio, E/e' ratio, myocardial performance index, global longitudinal systolic strain, left ventricular ejection fraction, peripheral vascular resistance, left ventricular cardiac output and left ventricular mass indexed for body surface area. The measurements of the maternal cardiac indices were standardized to remove the effects of maternal characteristics and elements from the medical history, and the adjusted values in the GDM group were compared to those in the non-GDM group. Likelihood ratios were derived for those indices that were altered significantly in GDM, and these were used to modify the prior risk derived from maternal demographic characteristics and medical history. The area under the receiver-operating-characteristics curve and the detection rate of GDM, at 10%, 20% and 40% false-positive rates, in screening by a combination of maternal factors with cardiovascular indices were determined., Results: The study population of 2853 pregnancies contained 199 (7.0%) that developed GDM. In pregnancies that developed GDM, there were significant differences from the non-GDM group in E/A ratio, E/e' ratio, myocardial performance index and global longitudinal systolic strain. After adjustment for maternal demographic characteristics and factors from the medical history known to affect cardiac indices, the only cardiovascular indices that were significantly different between the GDM and non-GDM groups were peripheral vascular resistance and myocardial performance index, both of which were marginally increased in the GDM group. The performance of screening for GDM by maternal demographic characteristics and medical history was not improved by the addition of cardiovascular indices., Conclusions: Women with GDM have subtle functional and hemodynamic cardiac changes prior to the development of GDM. These cardiac changes are mostly related to the adverse risk-factor profile of these women. Maternal cardiac assessment at 20 weeks does not offer additional predictive information for GDM development in pregnancy to that calculated based on demographic characteristics and medical history. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

Neonates with disseminated neonatal herpes simplex virus infection often present with cardiorespiratory failure. The pathophysiological contributors to the disease phenotype, biologic mechanisms underlying the hemodynamic instability and optimal approach to cardiovascular treatment have not been well described. We describe clinical and echocardiography features of cardiovascular dysfunction, in a case series of neonates with disseminated herpes simplex virus, and response to physiology-based hemodynamic management. The biologic phenotype includes low systemic vascular resistance state, hypovolemia secondary to third space losses, myocardial dysfunction and pulmonary hypertension. Early targeted neonatal echocardiography provided hemodynamic insights on blood flow, shunt characterization, vascular resistance and cardiac function, that were difficult to gauge clinically (eg, differentiating parenchymal from pulmonary vascular disease) thereby positively impacted clinical care. All patients were stabilized hemodynamically without utilizing extracorporeal membrane oxygenation, although all patients died of multiorgan failure., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In adult patients with pulmonary arterial hypertension (PAH), right ventricular (RV) failure may worsen rapidly, resulting in a poor prognosis. In this population, non-invasive assessment of RV function is challenging. RV stroke work index (RVSWI) measured by right heart catheterization (RHC) represents a promising index for RV function. The aim of the present study was to comprehensively evaluate non-invasive measures to calculate RVSWI derived by echocardiography (RVSWI ECHO ) using RHC (RVSWI RHC ) as a reference in adult PAH patients., Methods: Retrospectively, 54 consecutive treatment naïve patients with PAH (65 ± 13 years, 36 women) were analyzed. Echocardiography and RHC were performed within a median of 1 day [IQR 0-1 days]. RVSWI RHC was calculated as: (mean pulmonary arterial pressure (mPAP)-mean right atrial pressure (mRAP)) x stroke volume index (SVI) RHC . Four methods for RVSWI ECHO were evaluated: RVSWI ECHO-1  = Tricuspid regurgitant maximum pressure gradient (TR maxPG ) x SVI ECHO , RVSWI ECHO-2  = (TR maxPG -mRAP ECHO ) x SVI ECHO , RVSWI ECHO-3  = TR mean gradient (TR meanPG ) x SVI ECHO and RVSWI ECHO-4  = (TR meanPG -mRAP ECHO ) x SVI ECHO . Estimation of mRAP ECHO was derived from inferior vena cava diameter., Results: RVSWI RHC was 1132 ± 352 mmHg*mL*m -2 . In comparison with RVSWI RHC in absolute values, RVSWI ECHO-1 and RVSWI ECHO-2 was significantly higher (p < 0.001), whereas RVSWI ECHO-4 was lower (p < 0.001). No difference was shown for RVSWI ECHO-3 (p = 0.304). The strongest correlation, with RVSWI RHC , was demonstrated for RVSWI ECHO-2 (r = 0.78, p < 0.001) and RVSWI ECHO-1 ( r = 0.75, p < 0.001). RVSWI ECHO-3 and RVSWI ECHO-4 had moderate correlation (r = 0.66 and r = 0.69, p < 0.001 for all). A good agreement (ICC) was demonstrated for RVSWI ECHO-3 (ICC = 0.80, 95% CI 0.64-0.88, p < 0.001), a moderate for RVSWI ECHO-4 (ICC = 0.73 , 95% CI 0.27-0.87, p < 0.001) and RVSWI ECHO-2 (ICC = 0.55, 95% CI - 0.21-0.83, p < 0.001). A poor ICC was demonstrated for RVSWI ECHO-1 (ICC = 0.45, 95% CI - 0.18-0.77, p < 0.001). Agreement of absolute values for RVSWI ECHO-1 was - 772 ± 385 (- 50 ± 20%) mmHg*mL*m -2 , RVSWI ECHO-2 - 600 ± 339 (-41 ± 20%) mmHg*mL*m -2 , RVSWI ECHO-3 42 ± 286 (5 ± 25%) mmHg*mL*m -2 and for RVSWI ECHO-4 214 ± 273 (23 ± 27%) mmHg*mL*m -2 ., Conclusion: The correlation with RVSWI RHC was moderate to strong for all echocardiographic measures, whereas only RVSWI ECHO-3 displayed high concordance of absolute values. The results, however, suggest that RVSWI ECHO-1 or RVSWI ECHO-3 could be the preferable echocardiographic methods. Prospective studies are warranted to evaluate the clinical utility of such measures in relation to treatment response, risk stratification and prognosis in patients with PAH.

Accurate assessment of the left ventricular (LV) systolic function is indispensable in the clinic. However, estimation of a precise index of cardiac contractility, i.e., the end-systolic elastance ( E es from simple and readily available noninvasive measurements. The method is based on a validated model of the cardiovascular system and noninvasive data from arm-cuff pressure and routine echocardiography to render the model patient-specific. Briefly, the algorithm first uses the measured aortic flow as model input and optimizes the properties of the arterial system model to achieve correct prediction of the patient's peripheral pressure. In a second step, the personalized arterial system is coupled with the cardiac model (time-varying elastance model) and the LV systolic properties, including E es from simple and readily available noninvasive measurements. The method is based on a validated model of the cardiovascular system and noninvasive data from arm-cuff pressure and routine echocardiography to render the model patient-specific. Briefly, the algorithm first uses the measured aortic flow as model input and optimizes the properties of the arterial system model to achieve correct prediction of the patient's peripheral pressure. In a second step, the personalized arterial system is coupled with the cardiac model (time-varying elastance model) and the LV systolic properties, including E es , are tuned to predict accurately the aortic flow waveform. The algorithm was validated against invasive measurements of E es (multiple pressure-volume loop analysis) taken from n ) according to measurement of the patient's arm-cuff pressure and a routine echocardiography examination. The proposed method was validated in vivo against invasive multiple-loop measurements of n = 9 patients without heart failure. Invasive measurements of E es (median = 2.4 mmHg/mL, range = [1.0, 5.0] mmHg/mL) agreed well with method predictions (normalized root mean square error = 9%, ρ = 0.89, bias = -0.1 mmHg/mL, and limits of agreement = [-0.9, 0.6] mmHg/mL). This is a promising first step toward the development of a valuable tool that can be used by clinicians to assess systolic performance of the LV in the critically ill. NEW & NOTEWORTHY In this study, we present a novel model-based method to estimate the left ventricular (LV) end-systolic elastance ( E es ) according to measurement of the patient's arm-cuff pressure and a routine echocardiography examination. The proposed method was validated in vivo against invasive multiple-loop measurements of E es , achieving high correlation and low bias. This tool could be most valuable for clinicians to assess the cardiovascular health of critically ill patients.

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO 2 ) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO 2 . The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

Right-parasternal-view (RPV) often provides the best hemodynamic assessment of the aortic-valve-stenosis by echocardiography. However, no detailed study on patients with aortic prosthesis is available. Thus, RPV usefulness is left as an anecdotical notion in this context. We aimed to define feasibility and clinical-impact of RPV before and soon-after percutaneous implantation (TAVI) or surgical (SAVR) aortic-valve-replacement (AVR) for AS. Patients with severe-AS electively referred for AVR between September-2019 and February-2020 were prospectively evaluated. Echocardiographic examinations inclusive of apical and RPV to measure aortic-peak-velocity , gradients and area (AVA) were performed the day before AVR and at hospital discharge and compared by matched-pair-analysis. Forty-seven patients (mean age 79 ± 8 years, 63% female, ejection-fraction 61 ± 6%) referred for SAVR (24 [51%]) or TAVI (23 [49%]) were enrolled. RPV was feasible in 45 patients (96%) before-AVR but in only 32 after-AVR (68%), particularly after SAVR (50%) than TAVI (87% p = 0.005). RPV remained the best acoustic window after TAVI in 75% of cases. Hemodynamic assessment of TAVI, but not SAVR, invariably benefit from RPV versus apical evaluation (aortic-peak-velocity: 2.57 ± 0.39 vs 2.23 ± 0.47 m/sec, p = 0.002; mean gradient: 15 ± 5 vs 12 ± 5 mm Hg, p = 0.01). Five (11%) patients presented severe patient-prosthesis-mismatch, 4 of which were detectable only by RPV. This pilot-experience demonstrates that RPV feasibility is slightly reduced after AVR. RPV can improve the hemodynamic assessment of the prosthetic valve versus apical view, including the detection of patient-prosthesis-mismatch. Furthermore, when RPV is the best acoustic windows in patients with severe AS, it generally remains so after-TAVI., (Copyright © 2020 Elsevier Inc. All rights reserved.)