Search

Objective\ud\udStatistical shape modelling (SSM) has established as a powerful method for segmenting the left ventricle in cardiac magnetic resonance (CMR) images However, applying them to segment the right ventricle (RV) is not straightforward because of the complex structure of this chamber. Our aim was to develop a new inter-modality SSM-based approach to detect the RV endocardium in CMR data.\udMethods\ud\udReal-time transthoracic 3D echocardiographic (3DE) images of 219 retrospective patients were used to populate a large database containing 4347 3D RV surfaces and train a model. The initial position, orientation and scale of the model in the CMR stack were semi-automatically derived. The detection process consisted in iteratively deforming the model to match endocardial borders in each CMR plane until convergence was reached. Clinical values obtained with the presented SSM method were compared with gold-standard (GS) corresponding parameters.\udResults\ud\udCMR images of 50 patients with different pathologies were used to test the proposed segmentation method. Average processing time was 2 min (including manual initialization) per patient. High correlations (r2 > 0.76) and not significant bias (Bland-Altman analysis) were observed when evaluating clinical parameters. Quantitative analysis showed high values of Dice coefficient (0.87 ± 0.03), acceptable Hausdorff distance (9.35 ± 1.51 mm) and small point-to-surface distance (1.91 ± 0.26 mm). Conclusion\ud\udA novel SSM-based approach to segment the RV endocardium in CMR scans by using a model trained on 3DE-derived RV endocardial surfaces, was proposed. This inter-modality technique proved to be rapid when segmenting the RV endocardium with an accurate anatomical delineation, in particular in apical and basal regions.

Funding Acknowledgements WASE Normal Values Study is sponsored by American Society Echocardiography Foundation. OnBehalf the WASE Investigators Background Left ventricular (LV) stroke volume (SV) can be determined by multiple ultrasound methods, including Doppler, two- (2D) and three-dimensional (3D) echocardiography. However, how methods compare to each other is not well understood. In this report from the WASE study, we aim to examine and compare normal reference ranges for SV and SV index (SVI) obtained from healthy adults by Doppler, 2D Simpson’s and 3D methods. Methods WASE Normal Values Study is a multinational, observational, cross-sectional study. Individuals free from known cardiac, lung and renal disease were prospectively enrolled with even distribution among age groups and gender. Doppler, 2D and 3D datasets were acquired at the enrolling centers, following a standardized protocol. LV SV was measured by three methods: Doppler (LV outflow tract diameter and velocity time integral), 2D biplane Simpson’s rule and 3D volume method. SV was indexed by body surface area (SVI). All measurements were analyzed (TOMTEC) in two core laboratories (for 2D and 3D) following ASE Guidelines. Methods were compared by Friedman test and Bland-Altman analysis. Results As of May 2019, 646 cases have been analyzed in both 2D and 3D datasets. In this population, age was 45 ± 16 years old (range 18-85) and body surface area was 1.76 ± 0.22 m² (range 0.95-2.44). LV EF by 2D Simpson’s rule and 3D method were 63.2 ± 2.9 and 62.3 ± 5.0 %, respectively (p Conclusions Comparing 3 modalities in a large population of healthy individuals, SV and SVI are underestimated by 2D Simpson’s method. Given the large differences, combining 2D and Doppler or 3D measurements for hemodynamic calculations (such as regurgitant volumes and fraction) should be done with caution. Abstract 104 Figure.

Funding Acknowledgements WASE Normal Values Study is sponsored by American Society Echocardiography Foundation. OnBehalf the WASE Investigators Background The American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI) chamber quantification guidelines provide normal reference values for a variety of size and function parameters. While used worldwide, these were predominantly obtained from American and European Caucasian populations and may not represent individuals from other regions around the world. Accordingly, ASE in collaboration with its International Alliance Partners conducted the World Alliance of Societies of Echocardiography (WASE) Normal Values Study to establish and compare normal echocardiographic values across races, ethnicities and countries worldwide. While most previous studies focused on left ventricular (LV) size and ejection fraction, LV stroke volume (SV) in healthy normal subjects has not been well defined. In this report, we aim to examine similarities and differences in normal LV SV indexed by body surface area (SVI) among regions around the world. Methods WASE Normal Values Study is a multinational, observational, cross-sectional study. Individuals free from known cardiac, lung and renal disease were prospectively enrolled with even distribution among age groups and gender. Echocardiographic images were acquired following a standardized protocol. LV SV was assessed by Doppler-derived (LVOT diameter and VTI) and two-dimensional (2D) biplane Simpson’s methods. LV SVI was calculated to account for differences in body size. These measurements were analyzed (TOMTEC) in a single core laboratory following ASE/EACVI Guidelines. Results As of May 2019, LV SV has been analyzed in 1164 cases from 13 countries, representing 8 distinct regions worldwide. In this population, age, body surface area and 2D LV ejection fraction were 47 ± 17 years old (range 18-87 years old), 1.76 ± 0.22 m² (range 0.95-2.44 m²) and 63.2 ± 2.9 % (range 52.7-73.7 %), respectively. LV SV and SVI by Doppler were larger than those obtained by 2D method in all regions. LV SV and SVI in both methods had significant differences among regions (p< 0.0001, Kruskal-Wallis test). LV SV and SVI in South Asia (India) were smallest in both methods and were also significantly smaller than other Asian regions (Figure). North America and Europe had largest LV SV and SVI by Doppler method, while Oceania had largest values by 2D. Conclusions The WASE Normal Values Study shows geographical variability in LV SVI across continents and countries. This information should be considered when determining normative values for SV and SVI. Abstract P1766 Figure.

Aims To obtain the normal range for 2D echocardiographic (2DE) measurements of left ventricular (LV) layer-specific strain from a large group of healthy volunteers of both genders over a wide range of ages. Methods and results A total of 287 (109 men, mean age: 46 ± 14 years) healthy subjects were enrolled at 22 collaborating institutions of the EACVI Normal Reference Ranges for Echocardiography (NORRE) study. Layer-specific strain was analysed from the apical two-, three-, and four-chamber views using 2DE software. The lowest values of layer-specific strain calculated as ±1.96 standard deviations from the mean were −15.0% in men and −15.6% in women for epicardial strain, −16.8% and −17.7% for mid-myocardial strain, and −18.7% and −19.9% for endocardial strain, respectively. Basal-epicardial and mid-myocardial strain decreased with age in women (epicardial; P = 0.008, mid-myocardial; P = 0.003) and correlated with age (epicardial; r = −0.20, P = 0.007, mid-myocardial; r = −0.21, P = 0.006, endocardial; r = −0.23, P = 0.002), whereas apical-epicardial, mid-myocardial strain increased with the age in women (epicardial; P = 0.006, mid-myocardial; P = 0.03) and correlated with age (epicardial; r = 0.16, P = 0.04). End/Epi ratio at the apex was higher than at the middle and basal levels of LV in men (apex; 1.6 ± 0.2, middle; 1.2 ± 0.1, base 1.1 ± 0.1) and women (apex; 1.6 ± 0.1, middle; 1.1 ± 0.1, base 1.2 ± 0.1). Conclusion The NORRE study provides useful 2DE reference ranges for novel indices of layer-specific strain.

A 50-year-old man with severe rheumatic mitral stenosis was deemed too high risk for surgery and was referred for percutaneous balloon valvuloplasty. The valvuloplasty was successful in reducing the transmitral gradient and improving the patient’s symptoms; however, it was complicated by a tear in the posteromedial commissure and moderate mitral regurgitation. (Level of Difficulty: Beginner.)

Background Cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) is the gold standard for detection of myocardial scar. We hypothesized that CMR Feature Tracking (FT)-derived regional myocardial strain may reflect the presence of scar and could thus potentially be used instead of LGE imaging. Purpose The aim of this study was to determine the relationship between FT-derived regional myocardial strain and LGE in patients with coronary artery disease (CAD). Methods Seventy-five patients with CAD and typical ischemic LGE patterns on CMR (1.5T) were included (mean age 60±12 years, 70% males). Myocardial strain analysis and LGE identification were performed using dedicated commercial software. Scar was defined by presence of LGE in the same area of the myocardium in both short- and long-axis views. Peak systolic regional longitudinal and circumferential strain (RLS, RCS) values were calculated in the region of interest corresponding to the LGE area and also in a non-LGE myocardial region as a reference in each patient. These comparisons were repeated for a subgroup of 36 patients with left ventricular (LV) ejection fraction (EF) Results Both global longitudinal and circumferential strain values were abnormal (−12.8±5.1% and −11.4±4.1%, respectively), reflecting LV dysfunction in this CAD cohort (EF = 40±16%). The magnitude of both RLS and RCS was significantly reduced in areas of LGE, compared to those without LGE: RLS −10.0±5.8% versus −20.4±7.5% (p LGE and regional strain analysis. Conclusion Reduced magnitude of regional longitudinal and circumferential strain by CMR-FT correlates with presence of LGE. Pending further validation, this finding may constitute the basis for detection of scar without contrast enhanced imaging, and would result in reduced cost, scan time and risk associated with gadolinium. Acknowledgement/Funding ARP: Research support (software) from Neosoft and Philips

Background Echocardiographic quantification of left ventricular (LV) ejection fraction (EF) relies on either manual or automated identification of endocardial boundaries followed by standard calculation of model-based end-systolic and end-diastolic LV volumes. Recent developments in artificial intelligence resulted in computer algorithms that allow near automated detection of endocardial boundaries and measurement of LV volumes and function. However, boundary identification is still prone to errors limiting accuracy in certain patients. We hypothesized that a fully automated machine learning algorithm could be developed, which circumvents border detection and instead estimates the degree of ventricular contraction, similar to a human expert trained on tens of thousands of images. Purpose This study was designed to test the feasibility and accuracy of this approach. Methods Machine learning algorithm was developed and trained on a database of >50,000 echocardiographic studies, including multiple apical 2- and 4-chamber views, to automatically estimate LVEF (AutoEF, BayLabs). Testing was performed on an independent group of 99 unselected patients, whose automated EF values were compared to reference values obtained by averaging measurements by 3 experts using conventional volume-based technique. Inter-technique agreement was assessed using linear regression and Bland-Altman analysis of bias and limits of agreement (LOA). Consistency was assessed by mean absolute deviation (MAD) among automated estimates based on different combinations of apical views. Finally, sensitivity and specificity of detecting of EF≤35% was calculated. These metrics were compared side-by-side against the same reference standard to those obtained from conventional EF measurements by clinical readers. Results Automated estimation of LVEF was feasible in all 99 patients. AutoEF values showed high consistency (MAD=2.9%) and excellent agreement with the reference values: r=0.95, bias=1.0%, LOA=±11.8%, with sensitivity 0.90 and specificity 0.92 for detection of EF≤35%. This was similar to clinicians' measurements: r=0.94, bias=1.4%, LOA=±13.4%,sensitivity 0.93, specificity 0.87. Conclusions Machine learning algorithm for volume-independent LVEF estimation is highly feasible and similar in accuracy to conventional volume-based measurements, when compared to reference values provided by an expert panel. Acknowledgement/Funding Bay Labs, Inc.

BACKGROUND: Although analysis of cardiac magnetic resonance (CMR) images provides accurate and reproducible measurements of left ventricular (LV) volumes, these measurements are usually not performed throughout the cardiac cycle because of lack of tools that would allow such analysis within a reasonable timeframe. A fully-automated machine-learning (ML) algorithm was recently developed to automatically generate LV volume-time curves. Our aim was to validate ejection and filling parameters calculated from these curves using conventional analysis as a reference. METHODS: We studied 21 patients undergoing clinical CMR examinations. LV volume-time curves were obtained using the ML-based algorithm (Neosoft), and independently using slice-by-slice, frame-by-frame manual tracing of the endocardial boundaries. Ejection and filling parameters derived from these curves were compared between the two techniques. For each parameter, Bland-Altman bias and limits of agreement (LOA) were expressed in percent of the mean measured value. RESULTS: Time-volume curves were generated using the automated ML analysis within 2.5 ± 0.5 min, considerably faster than the manual analysis (43 ± 14 min per patient, including ~10 slices with 25–32 frames per slice). Time-volume curves were similar between the two techniques in magnitude and shape. Size and function parameters extracted from these curves showed no significant inter-technique differences, reflected by high correlations, small biases (< 10%) and mostly reasonably narrow LOA. CONCLUSION: ML software for dynamic LV volume measurement allows fast and accurate, fully automated analysis of ejection and filling parameters, compared to manual tracing based analysis. The ability to quickly evaluate time-volume curves is important for a more comprehensive evaluation of the patient’s cardiac function.

International audience; Aims - To obtain the normal ranges for 2D echocardiographic (2DE) indices of myocardial work (MW) from a large group of healthy volunteers over a wide range of ages and gender. Methods and results - A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from left ventricle (LV) pressure-strain loops. Peak LV systolic pressure was non-invasively derived from brachial artery cuff pressure. The lowest values of MW indices in men and women were 1270 mmHg% and 1310 mmHg% for GWI, 1650 mmHg% and 1544 mmHg% for GCW, and 90% and 91% for GWE, respectively. The highest value for GWW was 238 mmHg% in men and 239 mmHg% in women. Men had significant lower values of GWE and higher values of GWW. GWI and GCW significantly increased with age in women. Conclusion - The NORRE study provides useful 2DE reference ranges for novel indices of non-invasive MW.

A comprehensive cardiovascular magnetic resonance (CMR) exam includes assessment of regional wall motion, which typically involves qualitative interpretation by an experienced reader, although time-consuming quantitative measurements of myocardial wall thickening can be performed. Myocardial strain imaging offers the potential to more accurately quantify the extent and severity of regional wall motion abnormalities and has even been proposed as a mechanism to identify changes in regional contractility before they are visually evident1. Strain imaging may be particularly valuable to assess the impact of coronary artery disease on the myocardium because ischemia is known to first alter the longitudinal deformation of the subendocardial myocardial fibers prior to impacting the regional thickening in the radial direction that is required to create a visually appreciable wall motion abnormality1. In patients with chest pain, alterations in strain following the infusion of an inotrope such as dobutamine can be used to improve the detection of underlying coronary artery disease2. Myocardial strain can be measured using several different CMR-based tagging techniques, such as complementary spatial modulation of magnetization (C-SPAMM) 3 with harmonic phase encoding (HARP) post-processing 4,5, displacement encoding with stimulating echoes (DENSE) 6, cine phase contrast imaging, and strain-encoded CMR (SENC) 7–9. Additionally, it is also possible to use feature tracking algorithms to derive strain measurements from standard cine-CMR images 10,11. Each of these approaches has its advantages and limitations. Recent improvements in SENC-CMR allow for image acquisition to occur during a single heart beat in real time without sacrificing temporal resolution. Unlike the other strain imaging approaches, with SENC imaging being performed during a single heart beat, image quality is not significantly impacted by respiratory motion and arrhythmia. Previous single center studies have suggested that SENC-CMR can be used to improve the detection of coronary artery disease when compared to cine-image wall motion interpretation 12. In this multi-center study, we hypothesized that in the presence of coronary artery disease, changes in regional longitudinal and circumferential strain detected using SENC under intermediate-dose dobutamine stress CMR would precede changes in wall thickening visible on cine-CMR images.

International audience; Background: The long-term four-chamber cardiac remodelling after sinus rhythm restoration in atrial fibrillation is unknown.Methods: We prospectively evaluated 86 consecutive patients hospitalized for atrial fibrillation. Three-dimensional indexed volumes (3D Vi) and ejection fraction of the right (RA) left atria (LA) right (RV) and left ventricle (LV) were measured using transthoracic echocardiography at admission and at 12 months follow-up. Patients were divided into two groups according to restoration of sinus rhythm (n=47) or persistence of atrial fibrillation (n=39) post cardioversion, ablation or pharmacological therapy.Results: Compared to baseline values at one year the 3D Vi of both atria were smaller at ED and ES. in the sinus group. Interestingly, the RV was significantly smaller only in ES and unchanged in ED whereas the LV was larger in ED and unchanged is ES (Figure A). At one year the 3D ejection fraction of all cardiac chambers were improved (Figure C). In contrast, in the atrial fibrillation group at 12 months, there were no significant differences in 3D Vi of RA, LV and LA end-systolic Vi together with a significant increase of 3D RV Vi and LA end-diastolic Vi (Figure B). No significant changes in ejection fraction were noted in the RA, RV and LV but with a significant decrease LA ejection fraction (Figure D).Conclusion: The management of atrial fibrillation should be focused on restoration of sinus rhythm to improve cardiac remodelling and both atrial and ventricular ejection fractions.

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

Background Patent foramen ovale (PFO) has been linked to cryptogenic stroke, and closure has been reported to improve clinical outcomes. However, there are no clear guidelines to direct device sizing. This study sought to use patient characteristics and echocardiographic findings to create a prediction score for device sizing. Methods This was a retrospective review of patients undergoing percutaneous PFO closure at our institution between July 2010 and December 2014. Demographic and clinical characteristics were recorded, and all pre- and intraprocedural echocardiography results were evaluated. Results Thirty-six patients underwent percutaneous PFO closure during the study period. All procedures were performed using an Amplatzer Septal Occluder "Cribriform" (ASOC) device in one of three disc diameters: 25, 30, or 35 mm. Closure was indicated for cryptogenic stroke/transient ischemic attack in 75% of cases. Every case (100%) was successful with durable shunt correction at the 6-month follow-up without complications of erosion or device embolization. The presence of atrial septal aneurysm (ASA) (p = 0.027) and PFO tunnel length >10 mm (p = 0.038) were independently associated with increased device size. A scoring system of 1 point for male sex, 1 point for ASA, and 1 point for PFO tunnel >10 mm long was associated with the size of closure device implanted (p = 0.006). Conclusions A simple scoring system may be used to select an optimally sized device for percutaneous PFO closure using the ASOC device.

Current guidelines recommend that the atria be measured in 2D echocardiographic (2DE) apical views using the method-of-disks (MOD) or area-length (AL) technique as an alternative, although no definitive data exists that these are interchangeable. However, standard apical views maximize the long-axis of the left ventricle, rather than the dimensions of the atria, resulting in atrial foreshortening. We hypothesized that the increase in normal values of atrial volumes in the recent guidelines update was driven by data obtained using either the AL technique or dedicated atrial-focused views, which maximize the longitudinal dimension of the atria and thus provide larger volumes than the MOD measurements in standard apical views. We prospectively studied 30 patients (Philips iE33) to compare 2DE measurements of left and right atrial volumes (LAV, RAV) using the MOD and AL techniques in standard and atrial-focused views, against 3D echocardiography (3DE) derived volumes (QLab) as a reference. Compared to standard views, atrial-focused views provided significantly larger MOD volumes for both atria, which were in better agreement with 3DE, as reflected by higher correlation coefficients (LAV: r = 0.95 vs. 0.89; RAV: r = 0.89 vs. 0.84), smaller biases (LAV: -1 ml vs. 7 ml; RAV: 3 ml vs. 7 ml) and tighter limits of agreement. This was also the case for the AL measurements, which were minimally larger than the MOD values (NS) for both atria. In conclusion, atrial-focused views are a more accurate alternative to standard apical views, which provides larger volumes. This finding can explain the increase in the normal values in the recent guidelines update, which was mostly driven by the use of atrial-focused views, rather than by the differences between MOD and AL techniques. This understanding is essential in order to correctly integrate the revised normal values into clinical practice.

Background Echocardiographic assessment of left ventricular assist devices (LVADs) is used as a screening tool to evaluate the integrity and mechanics of the pump and circuit. We aimed to 1) establish the normal range and upper reference limit of peak velocity of the outflow cannula for the modern era of LVADs and 2) assess the clinical performance of the currently cited and newly proposed reference limits in patients with continuous-flow LVADs as a screening tool for cannula malfunction. Methods LVAD outflow peak CW velocities were measured with the use of Doppler transthoracic echocardiography (TTE) in 57 patients with LVADs (44 with Heartmate II (HM2), 13 with Heartware (HW)). The average velocity and the upper and lower normal reference limits (defined as ±2 standard deviations from the mean) for each LVAD type was calculated. The upper reference limit was then used as a screening threshold for cannula malfunction. Results The average outflow cannula peak velocity for the normal HM2 cohort was 1.86 ± 0.44 m/s with upper and lower reference limits of 2.73 m/s and 0.98 m/s, respectively. The average outflow cannula peak velocity for the normal HW cohort was 2.36 ± 0.53 m/s with upper and lower reference limits of 3.42 m/s and 1.3 m/s, respectively, which was significantly higher than the HM2 cohort ( P = .004). Conclusions In both HM2 and HW LVADs, the average peak outflow velocity and reference limit for the normal population, as measured by Doppler TTE, was markedly higher than the currently used LVAD reference limits of 2 m/s and are significantly different between devices. Patients with peak outflow velocities above our upper reference limits should be evaluated for LVAD outflow cannula malfunction.

Background Echocardiographic determination of left heart chamber volumetric parameters by using manual tracings during multiple beats is tedious in atrial fibrillation (AF). The aim of this study was to determine the usefulness of fully automated left chamber quantification software with single-beat three-dimensional transthoracic echocardiographic data sets in patients with AF. Methods Single-beat full-volume three-dimensional transthoracic echocardiographic data sets were prospectively acquired during consecutive multiple cardiac beats (≥10 beats) in 88 patients with AF. In protocol 1, left ventricular volumes, left ventricular ejection fraction, and maximal left atrial volume were validated using automated quantification against the manual tracing method in identical beats in 10 patients. In protocol 2, automated quantification–derived averaged values from multiple beats were compared with the corresponding values obtained from the indexed beat in all patients. Results Excellent correlations of left chamber parameters between automated quantification and the manual method were observed ( r = 0.88–0.98) in protocol 1. The time required for the analysis with the automated quantification method (5 min) was significantly less compared with the manual method (27 min) ( P r = 0.94–0.99), and test-retest variability of left chamber parameters was low (3.5%–4.8%). Conclusions Three-dimensional transthoracic echocardiography with fully automated quantification software is a rapid and reliable way to measure averaged values of left heart chamber parameters during multiple consecutive beats. Thus, it is a potential new approach for left chamber quantification in patients with AF in daily routine practice.

PURPOSE To examine a novel non-convex star ordering/shutter for reducing the number of breath-holds in cardiac three-dimensional (3D) T1 Mapping MRI with multiple breath-holds. METHODS A novel ordering, Non-Convex Star (NCS) was designed to acquire 3D volumes in a modified look-locker inversion recovery (MOLLI) T1 mapping sequence to provide more spatial resolution and coverage in fewer breath-holds. The proposed 3D-MOLLI approach using NCS was first validated in two phantoms using artifact power (AP) measurement against the fully sampled phantom. This was followed by an in vivo study in seven swine, in which the T1 values of the left ventricular (LV) myocardium divided into the American Heart Association (AHA) 16-segment model was compared against the reference multislice two-dimensional (2D) clinical reference and 3D volume without NCS breath-hold reduction. RESULTS NCS breath-hold reduction yielded less AP compared with the matched SENSE accelerated phantom volume (P

Objectives The goal of this study was to test the feasibility and accuracy of an automated algorithm that simultaneously quantifies 3-dimensional (3D) transthoracic echocardiography (TTE)-derived left atrial (LA) and left ventricular (LV) volumes and left ventricular ejection fraction (LVEF). Conventional manual 3D TTE tracings and cardiac magnetic resonance (CMR) images were used as a reference for comparison. Background Cardiac chamber quantification from 3D TTE is superior to 2D TTE measurements. However, integration of 3D quantification into clinical practice has been limited by time-consuming workflow and the need for 3D expertise. A novel automated software was developed that provides LV and LA volumetric quantification from 3D TTE datasets that reflect real-life manual 3-dimensional echocardiography measurements and values comparable to CMR. Methods A total of 159 patients were studied in 2 separate protocols. In protocol 1, 94 patients underwent 3D TTE imaging (EPIQ, iE33, X5-1, Philips Healthcare, Andover, Massachusetts) covering the left atrium and left ventricle. LA and LV volumes and LVEF were obtained using the automated software (HeartModel, Philips Healthcare) with and without contour correction, and compared with the averaged manual 3D volumetric measurements from 3 readers. In protocol 2, automated measurements from 65 patients were compared with a CMR reference. The Pearson correlation coefficient, Bland-Altman analysis, and paired Student t tests were used to assess inter-technique agreement. Results Correlations between the automated and manual 3D TTE measurements were strong (r = 0.87 to 0.96). LVEF was underestimated and automated LV end-diastolic, LV end-systolic, and LA volumes were overestimated compared with manual measurements. Agreement between the automated analysis and CMR was also strong (r = 0.84 to 0.95). Test–retest variability was low. Conclusions Automated simultaneous quantification of LA and LV volumes and LVEF is feasible and requires minimal 3D software analysis training. The automated measurements are not only comparable to manual measurements but also to CMR. This technique is highly reproducible and timesaving, and it therefore promises to facilitate the integration of 3D TTE-based left-heart chamber quantification into clinical practice.

Objectives The aim of this study was to develop a technique to measure regurgitant flow throughout the entire cardiac cycle that would more accurately measure aortic insufficiency (AI) severity in patients with continuous-flow left ventricular assist devices (CF-LVADs). Background AI is a common problem after CF-LVAD implantation. Current echocardiographic evaluation of AI does not take into account the unique flow properties present in patients with CF-LVADs. Methods In this prospective study, patients with LVADs who had varying degrees of AI (N = 20) underwent simultaneous right-sided heart catheterization (RHC) and transthoracic echocardiography (TTE). Regurgitant fraction (RF) across the aortic valve was calculated by subtracting the cardiac output obtained using the Fick method from the total systemic flow measured using the sum of the product of the velocity time integral and the cross-sectional area of the LVAD outflow cannula and aortic valve, respectively. The RFs were then compared with the following: 1) traditional TTE grading parameters; and 2) new TTE parameters unique to LVAD physiology, namely the diastolic flow acceleration and the systolic-to-diastolic peak velocity (S/D) ratio of the LVAD outflow cannula. Results Patients without evidence of AI had an RF approaching zero (2.4 ± 4.6%). Patients with trace and mild AI had an RF of 31.0 ± 5.4%, whereas patients with moderate or severe AI had an RF of 45.8 ± 3.6%. RF correlated better with pulmonary capillary wedge pressure (PCWP) than with vena contracta (correlation coefficient [R] = 0.73 vs. 0.56). The new TTE parameters (S/D ratio and diastolic acceleration) highly correlated with RF (R = 0.91 and 0.94, respectively) and more strongly correlated with PCWP than did vena contracta (R = 0.82 and 0.65 vs. 0.56). Conclusions RF measured by simultaneous RHC and TTE better correlates with clinical filling pressures than do traditional TTE parameters and may identify significant AI that could be underestimated using conventional measures. Novel TTE parameters, unique to CF-LVAD physiology, better correlate with RF and filling pressures than do our current TTE measurements.

Hypertensive disorders of pregnancy (HDP) are associated with subclinical changes in cardiac function. Although the mechanism underlying this finding is unknown, elevated levels of soluble antiangiogenic proteins such as soluble fms-like tyrosine kinase-1 (sFlt1) and soluble endoglin (sEng) are associated with myocardial dysfunction and may play a role. We hypothesized that these antiangiogenic proteins may contribute to the development of cardiac dysfunction in HDP. We prospectively studied 207 pregnant women with HDP and nonhypertensive controls and evaluated whether changes in global longitudinal strain (GLS) observed on echocardiography is specific for HDP and whether these changes correlate with HDP biomarkers, sFlt1 and sEng. A total of 62 (30%) patients were diagnosed with preeclampsia (group A), 105 (51%) did not have an HDP (group B), and 40 (19%) were diagnosed with chronic or gestational hypertension (group C). Blood was drawn and sFlt1 and sEng levels measured using enzyme-linked immunosorbent assay. Comprehensive echocardiograms, including measurement of GLS, were performed on all patients. Overall, GLS was worse in women in group A (preeclampsia) than those in group B or C. Increasing sFlt1 and sEng levels correlated with worsening GLS ( r =0.44 for sFlt1 and r =0.46 for sEng, both P r =0.18 and r =0.22, both P ≤0.01). Increasing levels also correlated with increasing left ventricular mass index, which also remained significant after multivariable analysis ( r =0.20 for sFlt1 and 0.19 for sEng, both P =0.01). Elevated circulating levels of antiangiogenic proteins in HDP correlate with and may contribute to myocardial dysfunction as measured by GLS.

Serial assessments of left ventricular ejection fraction (LVEF) are customary in patients with breast cancer receiving trastuzumab. Radionuclide angiography (RNA) is often used; however, a typical monitoring schedule could include 5 scans in a year. We evaluated the proportion of imaging-related ionizing radiation attributable to RNA in 115 patients with breast cancer, from 3 medical centers in the United States, Ireland, and Japan, who completed 12 months of trastuzumab treatment. Estimated radiation dose (ERD) was used to calculate exposure associated with imaging procedures spanning the 18 months before and after trastuzumab therapy. In addition, 20 cardiologists and oncologists from participating centers were surveyed for their opinions regarding the contribution of RNA to overall radiation exposure during trastuzumab treatment. When RNA was used to monitor LVEF, the mean ERD from imaging was substantial (34 ± 24.3 mSv), with the majority attributable solely to RNA (24.7 ± 14.8 mSv, 72.6%). Actual ERD associated with RNA in this population differed significantly from the perception in surveyed cardiologists and oncologists; 70% of respondents believed that RNA typically accounted for 0% to 20% of overall radiation exposure from imaging; RNA actually accounted for more than 70% of ERD. In conclusion, RNA was used to monitor LVEF in most patients in this cohort during and after trastuzumab therapy. This significantly increased ERD and accounted for a greater proportion of radiation than that perceived by surveyed physicians. ERD should be taken into account when choosing a method of LVEF surveillance. Alternative techniques that do not use radiation should be strongly considered.

International audience; We evaluate in this paper different strategies for the construction of a statistical shape model (SSM) of the left ventricle (LV) to be used for segmentation in cardiac magnetic resonance (CMR) images. From a large database of LV surfaces obtained throughout the cardiac cycle from 3D echocardiographic (3DE) LV images, different LV shape models were built by varying the considered phase in the cardiac cycle and the registration procedure employed for surface alignment. Principal component analysis was computed to describe the statistical variability of the SSMs, which were then deformed by applying an active shape model (ASM) approach to segment the LV endocardium in CMR images of 45 patients. Segmentation performance was evaluated by comparing LV volumes derived by ASM segmentation with different SSMs and those obtained by manual tracing, considered as a reference. A high correlation (r2 > 0.92) was found in all cases, with better results when using the SSM models comprising more than one frame of the cardiac cycle.

Severely reduced left ventricular (LV) ejection fraction (EF) derived from 2D echocardiographic (2DE) images is associated with increased mortality and used to guide therapeutic choices. Global longitudinal strain (GLS) is more sensitive than LVEF to detect abnormal LV function, and accordingly may help identify patients with mildly-to-moderately reduced LVEF who are at a similarly high cardiovascular (CV) risk. We hypothesized that 3D echocardiographic (3DE) measurements of EF and GLS, which are more reliable and reproducible, may have even better predictive value than the 2DE indices, and compared their ability to identify such patients. We retrospectively studied 104 inpatients with 2DE-derived LVEF of 30-50% who underwent transthoracic echocardiography during 2006-2010 period, had good quality images, and were followed-up through 2016. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Kaplan-Meier survival curves were generated for two subgroups defined by the median of each parameter as the cutoff. Of the 104 patients, 32 died of CV related causes. Cox regression revealed that 3D GLS was the only variable associated with CV mortality. Kaplan-Meier curves showed that 2D LVEF, 2D GLS and 3D EF were unable to differentiate patients at higher CV mortality risk, but 3D GLS was the only parameter to do so. Because 3D GLS is able to identify patients with mildly-to-moderately reduced LVEF who are at higher CV mortality risk, its incorporation into clinical decisions may improve survival of those who would benefit from therapeutic interventions not indicated according to the current guidelines.

Objectives We sought to: (1) determine the agreement in cardiovascular magnetic resonance (CMR) and speckle tracking echocardiography (STE) derived strain measurements, (2) compare their reproducibility, (3) determine which approach is best related to CMR late gadolinium enhancement (LGE). Background While STE-derived strain is routinely used to assess left ventricular (LV) function, CMR strain measurements are not yet standardized. Strain can be measured using dedicated pulse sequences (strain-encoding, SENC), or post-processing of cine images (feature tracking, FT). It is unclear whether these measurements are interchangeable, and whether strain can be used as an alternative to LGE. Methods Fifty patients underwent 2D echocardiography and 1.5 T CMR. Global longitudinal strain (GLS) was measured by STE (Epsilon), FT (NeoSoft) and SENC (Myocardial Solutions) and circumferential strain (GCS) by FT and SENC. Results GLS showed good inter-modality agreement (r-values: 0.71–0.75), small biases (

Non invasive assessment of left ventricular (LV) geometry and function is critically important for clinical decision making and represents the most frequent indication for an echocardiographic examination. Suitability for device implantation in patients with LV dysfunction, discontinuation of potentially cardiotoxic chemotherapy in cancer patients, indications to cardiac surgery or to treatment initiation in asymptomatic patients are among the most critical decisions that rely on an accurate measurement of LV ejection fraction. LV volume calculations by two-dimensional echocardiography is highly operator dependent, uses only partial information contained in a few predefined cross sections of the LV to assess global myocardial function, and relies on geometrical assumptions that may not be necessarily valid in every patient. In particular, geometric assumptions about LV shape make the calculations of LV volumes and ejection fraction more inaccurate in patients in whom this information is more critical (i.e. patients in whom there are extensive wall motion abnormalities or the LV geometry is distorted because of aneurysms). With three-dimensional echocardiography, we can measure (not calculate anymore!) LV volumes with no assumption regarding LV geometry. This technique has been extensively validated against cardiac magnetic resonance and was demonstrated to be more time-saving, reproducible, repeatable and accurate than conventional two-dimensional echocardiography for LV volumes and ejection fraction measurements.

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

The interest of both cardiologists (echocardiographers and interventional cardiologists) and cardiac surgeons about the tricuspid valve has been fueled by the association of better understanding of the role of tricuspid regurgitation as an independent determinant of patients’ morbidity and mortality, and the advent of novel transcatheter devices to treat severe tricuspid regurgitation in high surgical risk patients. However, conventional two-dimensional echocardiography is unsuitable to study the anatomy and the pathophysiological mechanisms of the regurgitant tricuspid valve because of the complex three-dimensional geometry of the valve and its anterior position in the mediastinum (just behind the sternum). Three-dimensional echocardiography has emerged as a very cost-effective imaging modality to: (1) Assess the anatomy of the tricuspid valve; (2) Measure the size/geometry of the tricuspid annulus; (3) Identify the mechanism of tricuspid regurgitation; (4) analyze the anatomic relationships between the tricuspid valve apparatus and the surrounding cardiac structures; (5) Measure the volumes and function of the right atrium and right ventricle.

Conventional 3-dimensional (3D) echocardiographic rendering does not consistently provide images with adequate detail definition and depth perception. Transillumination (TI) is a new 3D rendering tool that uses a freely movable virtual light to enhance image details and depth ([Figure 1][1]). This

The left ventricle has a unique shape that changes unpredictably in pathological conditions, and a complex mechanics due to a peculiar architectural arrangement of myocardial fibers. Both left ventricular geometry and mechanics cannot be comprehensively analyzed by exploring it with a tomographic imaging technique such as two-dimensional echocardiography (2DE). The need of making assumptions about left ventricular shape and mechanics to calculate geometrical and functional parameters from simple linear dimensions and area measurements is a major limitation of 2DE. Three-dimensional echocardiography, by encompassing the whole left ventricle in the acquisition volume, provides actual measurements of volumes, shape and mass, independent on any assumption about geometry, and allows to follow the motion of myocardial speckles frame-to-frame to allow actual measurement of the various components of myocardial deformation and ventricular torsion.

It is usually reported that only 10–15% of patients with tricuspid regurgitation have an organic (primary) etiology of the valve disease. However, it is likely that the actual prevalence of organic etiology of tricuspid regurgitation has been underestimated because of the technical limitations of conventional two-dimensional echocardiography to visualize the anatomy and assess the function of the tricuspid valve. However, the correct diagnosis of tricuspid regurgitation etiology and the assessment of valve anatomy are pivotal either to plan surgery or to select the most appropriate device and approach in interventional cardiology in patients who need tricuspid valve repair.

Accurate characterization of the normal anatomy and function of the mitral valve apparatus is key to understand the pathophysiology of mitral valve diseases. Echocardiography is the first-line imaging technique used for the assessment of the mitral valve morphology and function. During the last five decades, echocardiography has evolved from M-mode to two-dimensional, and then three-dimensional imaging, introducing a new era in the cardiovascular imaging. The use of newly matrix array transthoracic and transesophageal transducers bestowed unique possibilities to assess the mitral valve apparatus in all three or four-dimensions (including time), without the need of offline reconstruction. Heart imagers were able to obtain for the first time “en face” visualization of the mitral valve from the atrial perspective, as only the surgeons were previously able to see it, and to describe in detail the complex anatomy of the valvular and sub-valvular apparatus.

For decades, cardiac ultrasound had an important advantage over computed tomography and magnetic resonance imaging by virtue of its dynamic nature resulting in anatomically correct cross-sectional views of the beating heart. Nevertheless, it has remained limited to a single cut-plane at a time, necessitating sequential imaging of multiple views and considerable expertise to mentally align them in order to visualize the complex three-dimensional cardiac anatomy and detect abnormalities. Recent technological developments resulted in real-time three-dimensional ultrasound imaging of the heart, which is quickly conquering the clinical arena and adds unprecedented new dimensions to the diagnosis of heart disease. The goal of this chapter is to review the evolution of 3D echocardiography and describe the milestones this technology has gone through, and to highlight the promises and setbacks that drive the technological development towards the realization of its full potential.

Purpose The HeartMate 3 (HM3) left ventricular assist device (LVAD) is known to cause increased shear stress on the aortic wall related to the acceleration phase of the artificial pulse. We hypothesized that aortic compliance, as assessed by 2D transthoracic echocardiography (TTE), would be increased in patients with the HeartMate 3 LVAD as compared to the Heartmate 2 (HM2) or HeartWare HVAD, based on the hemodynamic properties of each device. Methods We identified 30 patients with HM3, HM2, and HVAD left ventricular assist devices, respectively. The groups did not differ significantly in terms of age, gender, or rates of hypertension, diabetes, or chronic kidney disease. For each patient, we identified the most recent echocardiogram with a recorded blood pressure at the time of the study. Ascending aortic diameters were measured 3 centimeters above the aortic valve in the parasternal long-axis view and used to calculate aortic strain and aortic distensibility, two markers of aortic compliance. The following calculations were used to obtain aortic strain and aortic distensibility: aortic strain = (aortic diameter end-systole - aortic diameter end-diastole) / aortic diameter end-diastole * 100 and aortic distensibility = 2 * aortic strain / pulse pressure * 1000. Results The HM3 had higher indices of aortic strain and aortic distensibility compared to the HM2 and HVAD patients, respectively. Aortic strain was significantly increased in the HM3 compared to the HM2 (8.3±3.1% vs. 6.2±1.9%, p=0.002) patients as well as compared to the HVAD patients (8.3±3.1% vs. 4.3±1.7%, p=0.0001). Aortic distensibility was not significantly increased between the HM3 and the HM2 patients (7.8±4.0 vs. 6.5±4.2 cm2dyne−110−3, p=0.23), but was significantly increased between the HM3 and the HVAD patients (7.8±4.0 vs. 4.4±2.6 cm2dyne−110−3, p=0.0002). Conclusion Echocardiographic markers of aortic compliance differ in HM3 LVADs compared to HM2 and HVAD models. This could be due to increased shear stress on the aortic wall in HM3 patients, though further studies with more robust methods of measuring aortic compliance are needed to confirm these results.

Purpose 2D transthoracic echocardiography (TTE) remains an integral component of imaging left ventricular assist devices (LVAD) and determining proper functionality of these devices. Despite relying heavily on transthoracic echocardiography, little is known about standardization of echocardiographic values and measurements pertinent to different types of devices (i.e. HeartMate II (HMII), Heartmate 3 (HM3), or HeartWare HVAD). Methods We identified 216 patients with HM3, HM2, and HVAD left ventricular assist devices. For each patient, we identified all transthoracic echocardiograms that had been performed post-LVAD implantation (n=489 TTEs). Peak outflow cannula velocities were measured using continuous wave Doppler from the right sternal border position on the chest (most co-axial to flow). Patients with incomplete continuous Doppler waveforms were excluded. Results Peak velocities were different for all three LVADs. The mean peak velocity for the HMII (n=289) was 1.74±0.575 m/s, the mean peak velocity for the HM3 (n=113) was 1.54±0.458 m/s and the mean peak velocity for the HVAD (n=87) was 2.07±0.762 m/s. The mean peak velocity for the HeartMate 2 was significantly different than the HeartMate 3 (p=0.0013). Similarly, the HeartMate 2 velocity was also different than the HeartWare HVAD (p=0.000011). When the mean peak velocities of the HeartMate 3 were compared with the HeartWare HVAD, statistical significance was also found (p=0.0000000039). Conclusion Mean peak outflow cannula velocities differ significantly in each of today's most commonly used LVADs. Different reference standards should be considered for each LVAD type.

Atrial fibrillation (AF) is associated with worsening tricuspid regurgitation (TR) in part due to adverse chamber remodeling. We sought to determine the impact of successful cardioversion (CV) for AF on chamber remodeling and TR. We prospectively evaluated 55 patients with AF (median duration of AF

Inpatient transthoracic echocardiography (TTE) is reimbursed as part of “bundled payments” in the current era of value-based healthcare. Thus, targeting TTE resources to impact optimal care is paramount. Limited TTE (L-TTE) shortens sonographer time and lower costs, and may be ideal for repeat

Prosthetic valve thrombosis can be a life threatening scenario. We present a case of mitral mechanical valve thrombosis that was successfully treated with catheter-directed thrombolytics. A 40 year old male with a history of atrial fibrillation on coumadin and mechanical mitral valve replacement

4D-flow is a cardiac magnetic resonance technique which allows quantification of blood flow in 3-dimensional space; however, adequate image quality requires the use of contrast agents. We developed a new 4D-flow approach (multiple overlapping thin slabs (MOTS)) capable of generating sufficient

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

Left atrial (LA) longitudinal strain is a novel parameter used for the evaluation of LA function, with demonstrated prognostic value in several cardiac diseases. However, the extent of load dependency of LA strain is not well known. The aim of this study was to evaluate the impact of acute changes in preload on LA strain, side by side with LA volume, in normal subjects.Twenty-five healthy volunteers (13 men; mean age, 31 ± 2 years) were prospectively enrolled, who underwent two-dimensional and three-dimensional echocardiographic imaging during acute stepwise reductions in preload using a tilt maneuver: baseline at 0°, followed by 40° and 80°. Left ventricular and LA size and function parameters were measured using standard methodology, and LA strain-time curves were obtained using speckle-tracking software (TomTec), resulting in reservoir, conduit, and contractile strain components. All parameters were compared among the three loading conditions using one-way analysis of variance for repeated measurements.Although there were no significant changes in blood pressure, heart rate increased significantly with tilt. As expected, LA volumes, left ventricular volumes, and left ventricular ejection fraction, as well as E wave, A wave, and e' significantly decreased with progressive inclination. In parallel, LA reservoir, conduit, and contractile strain values decreased with reduction in preload (reservoir: 42.9 ± 3.9% to 27.5 ± 3.8%, P .001; conduit: 29.3 ± 2.7% to 20.2 ± 5.0%, P .001; contractile: 13.6 ± 2.9% to 7.3 ± 3.5%, P .001). Paired post hoc analysis showed that all LA strain values were significantly different among all three tilt phases. Of note, percentage change in LA reservoir strain was significantly smaller than that in LA maximum volume.In normal subjects, LA strain is preload dependent but to a lesser degree than LA volume. This difference underscores the relative advantage of LA strain over maximum volume, when LA assessment is used as part of the diagnostic paradigm.