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Background LV volumes and LVEF measured by 3DE are more accurate and repeatable than those calculated with 2DE. However, the added prognostic value of 3DE LV volumes and EF remains to be clarified. Objectives To analyze if the left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have an incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory. Methods We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59±18 years) with various clinical indications referred for a routine clinical study. Results LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6±1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse otcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the association of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC= 0.84, p Conclusions 3DE LVEF and ESV showed stronger association with outcome than 2DE parameters LVEF measured by 3DE had a prognostic discriminatory power than 2D LVEF. Moreover, 3DE LV volumes threshold values for LV dilation had a higher discriminatory power and prognostic value than the corresponding 2DE values reported in current guidelines.

Background Although His bundle pacing (HBP) has been shown to improve left ventricular ejection fraction (LVEF), its impact on mitral regurgitation (MR) remains uncertain. Objectives The aim of this study was to evaluate change in functional MR after HBP in patients with left ventricular (LV) systolic dysfunction. Methods Paired echocardiograms were retrospectively assessed in patients with reduced LVEF (

The His-SYNC pilot trial was the first randomized comparison between His bundle pacing in lieu of a left ventricular lead for cardiac resynchronization therapy (His-CRT) and biventricular pacing (BiV-CRT), but was limited by high rates of crossover.To evaluate the results of the His-SYNC pilot trial utilizing treatment-received (TR) and per-protocol (PP) analyses.The His-SYNC pilot was a multicenter, prospective, single-blinded, randomized, controlled trial comparing His-CRT vs BiV-CRT in patients meeting standard indications for CRT (eg, NYHA II-IV patients with QRS120 ms). Crossovers were required based on prespecified criteria. The primary endpoints analyzed included improvement in QRS duration, left ventricular ejection fraction (LVEF), and freedom from cardiovascular (CV) hospitalization and mortality.Among 41 patients enrolled (aged 64 ± 13 years, 38% female, LVEF 28%, QRS 168 ± 18 ms), 21 were randomized to His-CRT and 20 to BiV-CRT. Crossover occurred in 48% of His-CRT and 26% of BiV-CRT. The most common reason for crossover from His-CRT was inability to correct QRS owing to nonspecific intraventricular conduction delay (n = 5). Patients treated with His-CRT demonstrated greater QRS narrowing compared to BiV (125 ± 22 ms vs 164 ± 25 ms [TR], P.001;124 ± 19 ms vs 162 ± 24 ms [PP], P.001). A trend toward higher echocardiographic response was also observed (80 vs 57% [TR], P = .14; 91% vs 54% [PP], P = .078). No significant differences in CV hospitalization or mortality were observed.Patients receiving His-CRT on-treatment demonstrated superior electrical resynchronization and a trend toward higher echocardiographic response than BiV-CRT. Larger prospective studies may be justifiable with refinements in patient selection and implantation techniques to minimize crossovers.

The importance of left ventricular (LV) global longitudinal strain (GLS) is increasingly recognized in multiple clinical scenarios. However, in patients with poor image quality, strain is difficult or impossible to measure without contrast enhancement. The feasibility of contrast-enhanced GLS measurement was recently demonstrated. We sought to determine: (1) whether contrast enhancement improves the accuracy of GLS measurements against cardiac magnetic resonance (CMR) reference, (2) their reproducibility compared to non-enhanced GLS, and (3) the dependence of accuracy and reproducibility on image quality. We prospectively enrolled 25 patients undergoing clinically indicated CMR imaging who subsequently underwent transthoracic echocardiography (TTE) with and without low-dose contrast injection (1–2 mL Optison/3–5 mL saline IV, GE Healthcare). GLS was measured from both non-contrast and contrast-enhanced images using speckle tracking (EchoInsight, Epsilon Imaging). These measurements were compared to each other and to CMR reference values obtained using feature tracking (SuiteHEART, NeoSoft). Inter-technique comparisons included linear regression and Bland–Altman analyses. A random subgroup of 15 patients was used to assess inter- and intra-observer variability using intra-class correlation (ICC). Contrast-enhanced GLS was in close agreement with non-enhanced GLS (r = 0.95; bias: − 0.2 ± 1.5%). Both inter-observer (ICC = 0.88 vs. 0.82) and intra-observer variability (ICC = 0.91 vs. 0.88) were improved by contrast enhancement. The agreement with CMR was better for contrast-enhanced GLS (r = 0.87; bias: 1.1 ± 2.2%) than for non-enhanced GLS (r = 0.80; bias: 1.3 ± 2.7%). In 12/25 patients with suboptimal TTE images that rendered GLS difficult to measure, contrast-enhanced GLS showed better agreement with CMR than non-enhanced GLS (r = 0.88 vs. 0.83) and also improved inter-observer (ICC = 0.83 vs. 0.76) and intra-observer variability (ICC = 0.88 vs. 0.82). In conclusion, contrast enhancement of TTE images improves the accuracy and reproducibility of GLS measurements, resulting in better agreement with CMR, even in patients with suboptimal acoustic windows. This approach may aid in the assessment of LV function in this patient population.

Objectives This study sought to evaluate the potential clinical impact of using 3-dimensional echocardiography (3DE) to measure left ventricular ejection fraction (LVEF) in patients considered for implantable cardioverter-defibrillator (ICD) implantation and to assess the predictive value of 3DE LVEF for arrhythmic events. Background ICD therapy is currently recommended to prevent sudden cardiac death in patients with symptomatic heart failure and LVEF ≤35%, and in asymptomatic patients with ischemic heart disease and LVEF ≤30%. Two-dimensional echocardiography (2DE) is currently used to calculate LVEF. However, 3DE has been reported to be more reproducible and accurate than 2DE to measure LVEF. Methods The study prospectively enrolled 172 patients with LV dysfunction (71% ischemic). Both 2DE and 3DE LVEF were obtained during the same study. The outcome was the occurrence of major arrhythmic events (sudden cardiac death, aborted cardiac arrest, appropriate ICD therapy). Results After a median follow up of 56 (range 18 to 65) months, major arrhythmic events occurred in 30% of the patients. Compared with 2DE, 3DE changed the assignment above or below the LVEF thresholds for ICD implantation in 20% of patients, most of them having 2DE LVEFs within ± 10% from threshold. By cause-specific hazard model, 3DE LVEF was the only independent predictor of the occurrence of major arrhythmic events. Conclusions LVEF by 3DE was an independent predictor of major arrhythmic events and improved arrhythmic risk prediction in patients with LV dysfunction. When compared with 2DE LVEF, 3DE measurement of LVEF may change the decision to implant an ICD in a sizable number of patients.

Aims Transthoracic 3D echocardiography (3DE) has been shown to be feasible and accurate to measure right ventricular (RV) ejection fraction (EF) when compared with cardiac magnetic resonance (CMR). However, RV EF, either measured with CMR or 3DE, has always been reported as normal (RV EF > 45%) or abnormal (RV EF ≤ 45%). We therefore sought to identify the partition values of RV EF to stratify RV dysfunction in mildly, moderately, or severely reduced as we are used to do with the left ventricle. Methods and results We used 3DE to measure RV EF in 412 consecutive patients (55 ± 18 years, 65% men) with various cardiac conditions who were followed for 3.7 ± 1.4 years to obtain the partition values which defined mild, moderate, and severe reduction of RV EF (derivation cohort). Then, the prognostic value of these partition values was tested in an independent population of 446 patients (67 ± 14 years, 58% men) (validation cohort). During follow-up, we recorded 59 cardiac deaths (14%) in the derivation cohort. Using K-Adaptive partitioning for survival data algorithm we identified four groups of patients with significantly different mortality according to RV EF: very low > 46%, 40.9% Conclusion Our study confirms the independent prognostic value of RV EF in patients with heart diseases, and identifies the partition values of RV EF to stratify the risk of cardiac death and MACE.

Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p

Three-dimensional echocardiography (3DE) allows accurate and reproducible measurements of right ventricular (RV) size and function. However, widespread implementation of 3DE in routine clinical practice is limited because the existing software packages are relatively time-consuming and skill demanding. The aim of this study was to test the accuracy and reproducibility of new machine learning- (ML-) based, fully automated software for three-dimensional quantification of RV size and function.Fifty-six unselected patients with a wide range of RV size and function and image quality, referred for clinically indicated cardiac magnetic resonance (CMR) imaging, underwent a transthoracic 3DE exam on the same day. End-systolic and end-diastolic RV volumes (ESV, EDV) and ejection fraction (EF) were measured using the ML-based algorithm and compared with CMR reference values using Bland-Altman and linear regression analyses.RV function quantification by echocardiography was feasible in all patients. The automatic approach was accurate in 32% patients with analysis time of 15 ± 1 seconds and 100% reproducible. Endocardial contour editing was necessary after the automated postprocessing in the remaining 68% patients, prolonging analysis time to 114 ± 71 seconds. With these minimal adjustments, RV volumes and EF measurements were accurate in comparison with CMR reference (biases: EDV, -25.6 ± 21.1 mL; ESV, -7.4 ± 16 mL; EF, -3.3% ± 5.2%) and showed excellent reproducibility reflected by coefficients of variation7% and intraclass correlations ≥0.95 for all measurements.The new ML-based 3DE algorithm provided accurate and completely reproducible RV volume and EF measurements in one-third of unselected patients without any boundary editing. In the remaining patients, quick minimal editing resulted in reasonably accurate measurements with excellent reproducibility. This approach provides a promising solution for fast three-dimensional quantification of RV size and function.

Aims The aim of this study is to explore the relationships of tricuspid annulus area (TAA) with right atrial maximal volume (RAVmax) and right ventricular end-diastolic volume (RVEDV) in healthy subjects and patients with functional tricuspid regurgitation (FTR) of different aetiologies and severities. Methods and results We enrolled 280 patients (median age 66 years, 59% women) with FTR due to left heart disease (LHD), pulmonary hypertension (PH), corrected tetralogy of Fallot (TOF), chronic atrial fibrillation (AF), and 210 healthy volunteers (45 years, 53% women). We measured TAA at mid-systole and end-diastole, tenting volume of tricuspid leaflets, RAVmax, and RVEDV by 3D echocardiography. Irrespective of TA measurement timing, TAA correlated more closely with RAVmax than with RVEDV in both controls and FTR patients. On multivariable analysis, RAVmax was the most important determinant of TAA, accounting for 41% (normals) and 56% (FTR) of TAA variance. In FTR patients, age, RVEDV, and left ventricular ejection fraction were also independently correlated with TAA. RAVmax (AUC = 0.81) and TAA (AUC = 0.78) had a greater ability than RVEDV (AUC = 0.72) to predict severe FTR (P Conclusion RA volume is a major determinant of TAA, and RA enlargement is an important mechanism of TA dilation in FTR irrespective of cardiac rhythm and RV loading conditions.

Background: Pulmonary capillary wedge pressure (PCWP) plays a pivotal role in cardiac disease diagnosis and management. Right heart catheterization (RHC) invasively provides accurate PCWP measurement, but it is impractical for widespread use in all patients. The left atrial expansion index (LAEI), measured on transthoracic echocardiography, describes the relative left atrial volume increase during the left atrial reservoir phase. The aim of this study was to validate LAEI as a noninvasive parameter for PCWP estimation. Methods: A total of 649 chronic cardiac patients (mean age, 66 ± 14 years; mean PCWP, 14 ± 7.6 mm Hg; mean left ventricular ejection fraction, 50 ± 15%) who underwent both clinically indicated RHC and transthoracic echocardiography within 24 hours were retrospectively enrolled. Patients were randomly divided into derivation (n = 509) and validation (n = 140) cohorts. PCWP was measured during RHC and defined as elevated when >12 mm Hg. Transthoracic echocardiographic parameters and LAEI were measured offline, blinded to RHC results. Results: In the derivation cohort, LAEI correlated logarithmically with PCWP, and the log-transformed LAEI (lnLAEI) correlated linearly with PCWP (r = −0.73, P < .001). lnLAEI showed an independent and additive predictive role for PCWP estimation over clinical and diastolic dysfunction (DD) parameters. The diagnostic accuracy of lnLAEI for elevated PCWP identification (area under the curve = 0.875, P < .001; optimal lnLAEI cutoff < 4.02) was higher than either the single DD parameters or their combination. In the validation cohort, lnLAEI cutoff < 4.02 showed higher accuracy than the 2016 DD algorithm (88% vs 74%) for elevated PCWP identification. Finally, the equation PCWP = 38.3 − 6.2 × lnLAEI, obtained from the derivation cohort, predicted invasively measured PCWP in the validation cohort. Conclusions: In a cohort of patients with various chronic cardiac diseases, lnLAEI performed better than DD parameters and the 2016 DD algorithm for PCWP estimation. lnLAEI might be a useful echocardiographic parameter for noninvasive PCWP estimation.

Introduction Right heart catheterization (RHC) is the reference technique for pulmonary capillary wedge pressure (PCWP) measurement but remains invasive. Transthoracic echocardiography (TTE) diastolic parameters (DPs) are used as non-invasive surrogates but have suboptimal accuracy. Left atrial expansion index (LAEI), describing LA reservoir function, could be used for indirectly estimate PCWP. Purpose To evaluate the correlation between LAEI and PCWP and to compare LAEI accuracy against DPs in estimating PCWP. Methods We retrospectively included the patients admitted to our department from 05/2015 to 02/2018 who underwent both a clinically indicated RHC and TTE within 24 hours. PCWP was obtained during RHC. DPs were measured offline and LAEI was calculated from LA maximum volume (MaxVol) and LA minimum volume (MinVol) as LAEI = [(LAMaxVol − LAMinVol) / LAMinVol)] × 100. Results We enrolled 405 patients (left ventricular ejection fraction (LVEF)12mmHg n=209). LAEI showed a logarithmic correlation with PCWP. The log-transformed LAEI (lnLAEI) had an excellent linear correlation (r=−0.82; p12 mmHg (lnLAEI AUC 0.921, p Conclusions LAEI is a simple parameter strongly associated with PCWP which might be used for PCWP estimation. Funding Acknowledgement Type of funding source: None

Background Right ventricular (RV) strain is a useful predictor of prognosis in various cardiovascular diseases, including those traditionally believed to impact only the left ventricle. We aimed to determine inter-modality and inter-technique agreement in RV longitudinal strain (LS) measurements between currently available cardiovascular magnetic resonance (CMR) and echocardiographic techniques, as well as their reproducibility and the impact of layer-specific strain measurements. Methods RV-LS was determined in 62 patients using 2D speckle tracking echocardiography (STE, Epsilon) and two CMR techniques: feature tracking (FT) and strain-encoding (SENC), and in 17 healthy subjects using FT and SENC only. Measurements included global and free-wall LS (GLS, FWLS). Inter-technique agreement was assessed using linear regression and Bland-Altman analysis. Reproducibility was quantified using intraclass correlation (ICC) and coefficients of variation (CoV). Results We found similar moderate agreement between both CMR techniques and STE in patients: r = 0.57–0.63 for SENC; r = 0.50–0.62 for FT. The correlation between SENC and STE was better for GLS (r = 0.63) than for FWLS (r = 0.57). Conversely, the correlation between FT and STE was higher for FWLS (r = 0.60–0.62) than GLS (r = 0.50–0.54). FT-midmyocardial strain correlated better with SENC and STE than FT-subendocardial strain. The agreement between SENC and FT was fair (r = 0.36–0.41, bias: − 6.4 to − 10.4%) in the entire study group. All techniques except FT showed excellent reproducibility (ICC: 0.62–0.96, CoV: 0.04–0.30). Conclusions We found only moderate inter-modality agreement with STE in RV-LS for both FT and SENC and poor agreement when comparing between the CMR techniques. Different modalities and techniques should not be used interchangeably to determine and monitor RV strain.

Background Cardiac magnetic resonance (CMR) flow quantification is typically performed using 2D phase-contrast (PC) imaging of a plane perpendicular to flow. 3D-PC imaging (4D-flow) allows offline quantification anywhere in a thick slab, but is often limited by suboptimal signal, potentially alleviated by contrast enhancement. We developed a non-contrast 4D-flow sequence, which acquires multiple overlapping thin slabs (MOTS) to minimize signal loss, and hypothesized that it could improve image quality, diagnostic accuracy, and aortic flow measurements compared to non-contrast single-slab approach. Methods We prospectively studied 20 patients referred for transesophageal echocardiography (TEE), who underwent CMR (GE, 3 T). 2D-PC images of the aortic valve and three 4D-flow datasets covering the heart were acquired, including single-slab, pre- and post-contrast, and non-contrast MOTS. Each 4D-flow dataset was interpreted blindly for ≥moderate valve disease and compared to TEE. Flow visualization through each valve was scored (0 to 4), and aortic-valve flow measured on each 4D-flow dataset and compared to 2D-PC reference. Results Diagnostic quality visualization was achieved with the pre- and post-contrast 4D-flow acquisitions in 25% and 100% valves, respectively (scores 0.9 ± 1.1 and 3.8 ± 0.5), and in 58% with the non-contrast MOTS (1.6 ± 1.1). Accuracy of detection of valve disease was 75%, 92% and 82%, respectively. Aortic flow measurements were possible in 53%, 95% and in 89% patients, respectively. The correlation between pre-contrast single-slab measurements and 2D-PC reference was weak (r = 0.21), but improved with both contrast enhancement (r = 0.71) and with MOTS (r = 0.67). Conclusions Although non-contrast MOTS 4D-flow improves valve function visualization and diagnostic accuracy, a significant proportion of valves cannot be accurately assessed. However, aortic flow measurements using non-contrast MOTS is feasible and reaches similar accuracy to that of contrast-enhanced 4D-flow.

Background Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection. Purpose We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF. Material and Methods we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF 80 ms; and GWI< 672 mmHg% to identify patients at risk of major arrhythmic events. Results During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF< 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF< 35%, and 0.77 (95%CI 0.68-0.86) for GWI 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)). Conclusions GWI< 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF

Biventricular pacing (BiV) is established as the primary modality to achieve cardiac resynchronization therapy (CRT), although nonresponse rates approach 30% to 40% [(1)][1]. His bundle pacing has emerged as a viable option for CRT with physiological restoration of electrical synchrony by

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 (

Aims Right ventricular free wall longitudinal strain (RVFWLS) has been proposed as an accurate and sensitive measure of right ventricular function that could integrate other conventional parameters such as tricuspid annulus plane systolic excursion (TAPSE) and fractional area change (FAC%). The aim of the present study was to evaluate the relationship between RVFWLS and outcomes in stable asymptomatic outpatients with left-sided structural heart disease. Methods and results We enrolled 458 asymptomatic patients with left-side heart diseases and any ejection fraction who were referred for echocardiography to two Italian centres. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome of this analysis. After a mean follow-up of 5.4 ± 1.2 years, 145 patients (31%) reached the combined endpoint. Most of echocardiographic parameters were related to outcomes, including right ventricular functional parameters. Mean value of RVFWLS in our cohort was −21 ± 8% and it was significantly related to the combined endpoint and in multivariable Cox-regression model; when tested with other echocardiographic parameters that were significantly related to outcome at univariate analysis, RVFWLS maintained its independent association with outcome (hazard ratio 0.963, 95% confidence interval 0.948–0.978; P = 0.0001). The best cut-off value of RVFWLS to predict outcome was −22% (area under the curve 0.677; P Conclusion RVFWLS may help clinicians to identify patients with left-sided structural heart disease at higher risk for first heart failure hospitalization and death for any cause.

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.

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

Introduction: Quantification of left ventricular (LV) size and function represents the most frequent indication for an echocardiographic study. New echocardiographic techniques have been developed over the last decades in an attempt to provide a more comprehensive, accurate, and reproducible assessment of LV function. Areas covered: Although two-dimensional echocardiography (2DE) is the recommended imaging modality to evaluate the LV, three-dimensional echocardiography (3DE) has proven to be more accurate, by avoiding geometric assumptions about LV geometry, and to have incremental value for outcome prediction in comparison to conventional 2DE. LV shape (sphericity) and mass are actually measured with 3DE. Myocardial deformation analysis using 3DE can early detect subclinical LV dysfunction, before any detectable change in LV ejection fraction. Expert opinion: 3DE eliminates the errors associated with foreshortening and geometric assumptions inherent to 2DE and 3DE measurements approach very closely those obtained by CMR (the current reference modality), while maintaining the unique clinical advantage of a safe, highly cost/effective, portable imaging technique, available to the cardiologist at bedside to translate immediately the echocardiography findings into the clinical decision-making process

Three-dimensional echocardiography (3DE) represents one of the most innovative advances in cardiovascular imaging over the last 20 years. Recent technological developments have fueled the full implementation of 3DE in clinical practice and expanded its impact on patient diagnosis, management, and prognosis. One of the most important clinical applications of transthoracic 3DE has been the quantitation of cardiac chamber volumes and function. The main limitations affecting two-dimensional echocardiography calculations of chamber volumes (i.e. geometric assumptions about cardiac chamber shape and view foreshortening) are overcome by 3DE that allows an actual measurement of their volumes. Transesophageal 3DE has been applied mainly to assess the anatomy and function of heart valves, congenital defects and masses in the beating heart. As reparative cardiac surgery and transcatheter procedures have become more and more popular to treat structural heart disease, transesophageal 3DE has become not only one of the main imaging modalities for procedure planning but also for intra-procedural guidance and assessment of procedural results. New image rendering modalities such as 3D printing, holographic display, and fusion of 3DE images with other radiological or nuclear modalities will further expand the clinical applications and indications of 3DE.

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

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.

Background The 2015 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for chamber quantification suggest new abnormality threshold and severity partition values for left atrial (LA) volume that are equally valid for the biplane method of disk (MOD) summation and the area-length method (ALM). However, they have never been clinically validated. Thus, we compared the clinical and prognostic impact of LA volume assessed by MOD and ALM by using both the 2015 and 2005 abnormality thresholds. Methods In a retrospective study of 467 patients with sinus rhythm and various cardiac conditions (median age 61 years, 68% men), maximal LA volumes were measured with MOD and ALM. Patients were followed for 3.7 ± 1.1 years to record both all-cause mortality and cardiac death. Results Applying the 2015 cutoff values, 21% of patients with dilated LA according to the 2005 recommendations were reclassified as normal. Severity of LA dilatation was reclassified in 48% (222/467) patients. ALM provided significantly larger LA volumes than MOD (41 [32; 58] mL/m2 vs 39 [30; 55] mL/m2; P =.0150), reclassifying 18% (84/467) of patients. Patients who died had larger LA volumes measured with both MOD (57 [38; 77] mL/m2 vs 37 [30; 51] mL/m2; P

Background: The study aimed (1) to assess the prognostic value of three-dimensional echocardiography (3DE) derived right ventricular (RV) ejection fraction (EF) and (2) to evaluate relative prognostic importance of reduced and preserved left ventricular (LV) EF and RVEF to predict all-cause mortality and cardiac death in a large cohort of patients with cardiac diseases. Methods: LV and RV volumes and EF were assessed by 3DE in 394 patients with various cardiovascular diseases. Patients were divided into four groups: (1) normal LVEF (≥50%) and normal RVEF (≥45%), n = 183; (2) reduced LVEF (

Cardiac resynchronization therapy (CRT) with coronary sinus leads is known to ameliorate mitral regurgitation (MR). There is a paucity of data, however, on the impact of His-bundle pacing (HBP) on MR. Patients with paired echocardiograms before and after HBP were retrospectively analyzed. MR was

Assessment of myocardial strain using cardiac magnetic resonance (CMR) provides important insight into myocardial abnormalities. Both global longitudinal and circumferential strain (GLS and GCS) can be quantified using either dedicated pulse sequences such as strain-encoding (SENC) or algorithms