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Left ventricular (LV) circumferential strain has received less attention than longitudinal deformation, which has recently become part of routine clinical practice. Among other reasons, this is because of the lack of established normal values. Accordingly, the aim of this study was to establish normative values for LV circumferential strain and determine sex-, age-, and race-related differences in a large cohort of healthy adults.

Cardiac resynchronisation therapy (CRT) can profoundly improve outcome in selected patients with heart failure; however, response is difficult to predict and can be absent in up to one in three patients. There has been a substantial amount of interest in the echocardiographic assessment of left ventricular dyssynchrony, with the ultimate aim of reliably identifying patients who will respond to CRT. The measurement of myocardial deformation (strain) has conventionally been assessed using tissue Doppler imaging (TDI), which is limited by its angle dependence and ability to measure in a single plane. Two-dimensional speckle-tracking echocardiography is a technique that provides measurements of strain in three planes, by tracking patterns of ultrasound interference (‘speckles’) in the myocardial wall throughout the cardiac cycle. Since its initial use over 15 years ago, it has emerged as a tool that provides more robust, reproducible and sensitive markers of dyssynchrony than TDI. This article reviews the use of two-dimensional and three-dimensional speckle-tracking echocardiography in the assessment of dyssynchrony, including the identification of echocardiographic parameters that may hold predictive potential for the response to CRT. It also reviews the application of these techniques in guiding optimal LV lead placement pre-implant, with promising results in clinical improvement post-CRT.

Left atrial (LA) evaluation includes volumetric and functional parameters with an abundance of diagnostic and prognostic implications. Solid normal reference ranges are compulsory for accurate interpretation in individual patients, but previous studies have yielded mixed conclusions regarding the effects of age, sex, and/or race. The present report from the World Alliance Societies of Echocardiography study focuses on two-dimensional (2D) and three-dimensional (3D) measures of LA structure and function, with subgroup analysis by age, sex, and race.

Recent advances in mitral valve (MV) percutaneous interventions have escalated the need for a more quantitative and comprehensive assessment of the MV, which can be best achieved by 3D echocardiography. Understanding normal valve size, structure and function is essential for differentiation of healthy from disease states. We aimed to establish normative values for the MV apparatus size and morphology and determine how they vary across age, sex and race groups, using data from the World Alliance of Societies of Echocardiography (WASE) normal values study.

Introduction:In mitral valve replacement (MVR), sudden increase in afterload and disruption of the annular-chordal-papillary-left-ventricular wall causes LV dysfunction in the early postoperative period. Preservation of the posterior mitral leaflet apparatus (MVR-P) has a favourable outcome on LV function. However, there is paucity of data on the impact of complete preservation of the sub-valvular apparatus (MVR-C).Objective:We investigated the impact of MVR-P and MVR-C on baseline and 3-months postoperative LV ejection fraction (EF) and global longitudinal strain (GLS).Methods:We retrospectively analysed a cohort of 29 MVR-P and 19 MVR-C patients with complete echo data at our unit, who were operated between 2012-2017. Between-group changes in LVEF and GLS were compared using independent sample T-test.Results:Median age was 59 years (IQR 50-69 years). Baseline LVEF was 58% (51 - 60%). Baseline GLS was -18.4 (-21.2 - -15.5). There were no significant differences between all baseline demographics including age (p=0.45), underlying MV pathology (p=0.1), baseline LVEF (p=0.48) and GLS (p=0.15). There was significantly less worsening of GLS in MVR-C group as compared to the MVR-P group (p=0.023), indicating better preservation of LV function. There was also a lower decrease in LVEF in the MVR-C as compared to the MVR-P group, although the difference was not statistically significant (p=0.23).Conclusion:MVR with complete preservation of the sub-valvular apparatus shows a favourable impact on the longitudinal function of the heart at 3 months. Further studies with larger patient numbers are indicated to investigate the long-term results of this surgical approach.

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Characteristic Doppler echocardiographic abnormalities were noted in five patients with a failing tissue prosthesis shown to have severe regurgitation and no evidence of obstruction. The audio signal was musical in quality and the regurgitant flow pattern was bidirectional and striated. There were 4 to 6 striations in the mitral and 18 in the aortic regurgitant jets per 100 cm/s length of signal. Pulsed Doppler ultrasound localized the jet to the valve in all cases although angiography failed to localize it in one of four cases.

Echocardiographic assessment of right ventricular (RV) systolic function is an important component of clinical decision making. Although professional societies have worked to define normal ranges of RV size and function, their guidelines have not included the impacts of age, sex, and ethnicity on these parameters, as they have for the left ventricle. The World Alliance of Societies of Echocardiography study was designed to investigate the effects of age, sex, and ethnicity on all cardiac chambers. The aim of this study was to explore whether these differences exist for RV systolic parameters.

Though the assessment of right ventricular (RV) diastolic function is feasible, it has garnered far less momentum for use compared to its left ventricular counterpart. The scarcity of data defining normative RV diastolic function and the fact that implications of RV diastolic dysfunction in different disease states on outcomes are less well known, both hinder integration into routine clinical assessment. We sought to establish normal values of RV diastolic parameters stratified by sex, age and race using data from the World Alliance of Societies of Echocardiography (WASE) Study.

Accurate measurements of the aortic annulus and root are important for guiding therapeutic decisions regarding the need for aortic surgery. Current echocardiographic guidelines for identification of aortic root dilatation are limited because current normative values were derived predominantly from white individuals in narrow age ranges, and based partially on M-mode measurements. Using data from the World Alliance Societies of Echocardiography (WASE) Study, we sought to establish normal ranges of aortic dimensions across sexes, races and a wide range of ages.

Assessment of cardiac output (CO) and stroke volume (SV) is essential to understand cardiac function and hemodynamics. These parameters can be examined using three echocardiographic techniques (pulsed-wave Doppler, two-dimensional [2D], and three-dimensional [3D]). Whether these methods can be used interchangeably is unclear. The influence of age, sex, and ethnicity on CO and SV has also not been examined in depth. In this report from the World Alliance of Societies of Echocardiography Normal Values Study, the authors compare CO and SV in healthy adults according to age, sex, ethnicity, and measurement techniques.

Myocardial scar appears brighter compared to normal myocardium in echocardiography due to differences in tissue characteristics. We tested how different ultrasound pulse characteristics impact on the brightness contrast (i.e. contrast ratio, CR) between tissues of different acoustic properties, as well as the accuracy of assessing tissue volume.

Echocardiography remains the most widely used modality to assess left ventricular (LV) chamber size and function. Currently this assessment is most frequently performed using 2D echocardiography (2DE). Yet, 3D echocardiography (3DE) has been shown to be more accurate and reproducible than 2DE. Current normative reference values for 3D LV analysis are predominantly based on data from North America and Europe. The World Alliance of Societies of Echocardiography (WASE) study was a designed to sample normal subjects from around the world to provide more universal global reference ranges. In this study we sought to assess the world-wide feasibility of LV 3DE and report on size and function measurements.

COVID-19 infection is known to cause a wide array of clinical chronic sequelae but little is known regarding the long-term cardiac complications. We aim to report echocardiographic follow-up findings and describe the changes in left and right ventricular function that occur following acute infection.

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease1. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined ‘standard’ two dimensional and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.

Healthcare delivery is being transformed by COVID-19 to reduce transmission risk but continued delivery of routine clinical tests is essential. Stress echocardiography is one of the most widely used cardiac tests in the NHS. We assessed the impact of the first (W1) and second (W2) waves of the pandemic on ability to deliver stress echocardiography. Clinical echocardiography teams in 31 NHS hospitals participating in the EVAREST study were asked in July and November 2020 to complete a survey on the structure and delivery of stress echocardiography as well as impact on patients and staff. Results were compared to stress echocardiography activity in the same centre during January 2020. 24 and 19 NHS hospitals completed the survey in July and November, respectively. A 55% reduction in the number of studies performed was reported in W1, recovering to exceed pre-COVID rates in W2. The major change was in mode of stress delivery. 70% of sites stopped their exercise stress service in W1, compared to 19% in W2. In those still using exercise during W1, 50% were wearing FFP3/N95 masks, falling to 38% in W2. There was also significant variability in patient screening practices with 7 different pre-screening questionnaires used in W1 and 6 in W2. Stress echocardiography delivery restarted effectively after COVID-19 with adaptations to reduce transmission that means activity has been able to continue, and exceed, pre-COVID-19 levels during the second wave. Further standardisation of protocols for patient screening and PPE may help further improve consistency of practice within the UK.

Introduction:Cardiac troponin T (cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) have both been associated with myocardial ischemia, but it remains unclear whether this is directly caused by ischemia or if the elevation is indirect and related myocardial dysfunction.Objective:To evaluate the associations between cTnT and NT-proBNP and the presence of reversible and irreversible myocardial perfusion defects, regional wall motion abnormalities, and myocardial scar.Methods:We included 432 patients from the European multicenter DOPPLER-CIP study with suspected stable coronary artery disease (SCAD) which was examined with SPECT at rest and during stress to assess reversible and irreversible ischemia. Patients also underwent stress electrocardiography, stress echocardiography and gadolinium enhanced MRI.Results:Reversible perfusion defects were present in 32%, and cTnT and NT-proBNP (median [IQR]) were higher in these patients: 9.5 (6.3-12.6) vs 7.0 (4.1-10.5) ng/L and 164 (80-336) vs 80 (43-166) ng/L (p<0.001). The two biomarkers correlated moderately (rho=0.50, p<0.001), and both were associated with reversible and irreversible ischemia assessed by hypoperfusion, hypokinesis and myocardial scar after adjusting for clinical covariates (Panel A) and after further adjustment for LV mass and LV ejection fraction. There was a trend for a stronger correlation with hypokinesis compared to hypoperfusion for both biomarkers. The C-statistics ranged from 63%-73% and were comparable between cTnT and NT-proBNP (P>0.50 in all models, Panel B), which was superior to stress electrocardiography and ?echocardiography ranging from 43%-56% and 52%-58%, respectively.Conclusions:Despite a significant association with ischemia, the diagnostic value of cTnT and NT-proBNP in SCAD seems modest. Our data suggest that the functional effects of myocardial ischemia may be a stronger stimulus for release of these biomarkers than ischemia per se.