Background: Left ventricular (LV) strain in echocardiography has been utilized as a determinant of myocardial function and a predictor of LV dysfunction prior to a reduction in ejection fraction. However, it is not known if changes in baseline LV strain can predict ischemia. Methods: This single center retrospective study at the University of Cincinnati aimed to evaluate the predictive value of baseline LV global longitudinal strain (GLS) obtained prior to stress echocardiogram (sEcho) for detecting myocardial ischemia in moderate risk patients undergoing evaluation for coronary artery disease (CAD). The study included 118 patients who underwent sEcho for CAD evaluation. Baseline LV GLS was measured in the apical 4 chamber, apical 2 chamber, and parasternal long axis views using Phillips or General Electric machines. Patients were divided into two groups based on pre-stress GLS values: GLS < -16% (n=67, 56.8%) and GLS ≥ -16% (n=51, 43.2%). Results: The mean age of the patients was 53.6±12.1 years, 55.9% were women, and 31.4% belonged to a non-white racial or ethnic group. The average baseline GLS values were -19.1%±2.4 and -13.5%±2.0 for patients in the GLS < -16% and GLS ≥ -16% baseline strain groups, respectively. Overall, 5.1% of the study population had a positive sEcho. Only one patient with GLS < -16% had a positive sEcho (P=0.038). The negative predictive value of GLS < -16% for a positive stress test was 98.5%. Conclusions: Assessing baseline LV GLS prior to sEcho could be a cost-effective and efficient predictor of stress outcomes in moderate-risk patients undergoing evaluation for CAD. Our results suggest that a baseline GLS value < -16% has a high negative predictive value for myocardial ischemia detected by sEcho. However, larger studies in more diverse populations are needed to confirm these findings.
Introduction and objectives：Traditional transcatheter closure of atrial septal defect (ASD) via the femoral vein carries risk of radiation damage. Transcutaneous closure of ASD under echocardiography guidance avoids radiation exposure and can be gradually applied. An alternative is to transcutaneous closure of ASD trans-jugular with an adjustable curved sheath under echocardiography guidance. Methods: We retrospectively studied all cases of trans-jugular transcutaneous closure of ASD with an adjustable curved sheath under echocardiography guidance in the Heart Center of Henan Province People’s Hospital between 2016 and December 2022. Results: 156 patients were included, 74 males and 82 females. Mean age was 6.9 ± 7.4 years and weight 23.7 ± 14.6 kg. Mean sizes of the ASD and occluder were (9.7 ± 4.7) mm and (14.1 ± 5.7) mm. The mean operation time was (49.6 ± 29.2) min. No complications such as atrioventricular block, reoperation, or pericardial effusion occurred. There are 3 patients had a residual shunt. All patients were followed-up for (38.7 ± 11.0)months. The 3 patients with residual shunt had self-closed at the 3-6-12months follow-up. There was no complication at follow-up. Conclusion: Trans-jugular transcutaneous closure of ASD with adjustable curved sheath under echocardiography guidance is safe, effective and minimally invasive.
Background: Cardiovascular diseases are leading causes of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cardiac involvement in SLE can often go undetected. Three-dimensional (3D) speckle tracking echocardiography (STE) is a noninvasive imaging technique that can assess the function of the heart’s ventricles in an accurate and reproducible way. This makes it an attractive option for detecting early signs of heart disease in SLE patients. By identifying these subclinical cardiac abnormalities, 3D-STE may help reduce the negative impact of cardiovascular diseases in SLE population. Methods: This cross-sectional study was undertaken to compare the left ventricular (LV) function between patients with SLE compared to age- and gender-matched controls using Two-dimensional (2D) and 3D-STE. A total of 52 SLE patients and 53 controls without any known cardiovascular events were included in the study. Patients’ past medical and drug history were collected through evaluating medical records and questionnaires. 2D and 3D-STE measured various left ventricular parameters. Results: The current study found no significant differences in left ventricle ejection fraction, left ventricle end-diastolic volume, left ventricle end-systolic volume, left ventricle end-diastolic mass, and left ventricle end-systolic mass between the two groups. However, the SLE group exhibited a a significantly lower global longitudinal strain (GLS) compared to the control groupaccording to all types of echocardiographic assessments, including 3D and 2D long-axis strain (LAX), apical 2-chamber (A2C), and apical 4-chamber (A4C) assessments (all P-values<0.05). Furthermore, a good inter- intra-rater reliability was observed regarding the GLS measurement with 3D-STE. Additionally, the study identified a significant correlation between GLS and SLE duration (r (50) = 0.46, P= 0.04). The use of prednisolone and nephrology disorders were also found to impact GLS measurements. Conclusion: Despite a normal LVEF in patients with SLE, GLS measuemetns indicated that LV systolic dysfunction was observed more frequently in SLE patients compared to their healthy counterparts. Therefore, advanced 3D-STE techniques may be useful in identifying subtle abnormalities in LV function in SLE patients.
Effective treatment, but also proper diagnosis of cardiovascular diseases, remains a major challenge in everyday practice. A quick, safe, and economically acceptable non-invasive procedure should play a leading role in cardiovascular risk assessment before invasive diagnostics is performed. The staging of subclinical atherosclerosis may help in further clinical decisions. Safe, widely available, and relatively inexpensive, ultrasonography is a promising examination that should find wider application in clinical practice. The latest ESC guidelines emphasize the usefulness of carotid ultrasound in the diagnosis of coronary artery disease (CAD) and subclinical assessment of atherosclerosis, which help to determine the level of cardiovascular risk. Ultrasound examination of peripheral arteries, especially superficial vessels such as the femoral arteries, is quite easy, quick, and accurate. Other vascular beds, such as iliac and renal, are more demanding to examine, but can also provide valuable information. This review summarizes important studies comparing the severity of atherosclerosis in ultrasound-visible vascular beds in patients with established CAD. We especially emphasize the benefits of the combined assessment of atherosclerosis features, which were characterized by high sensitivity and specificity in the diagnosis of CAD and other serious cardiovascular diseases.
Background The purpose of the study was to determine the association between vena contracta area (VCA) and secondary leaflet tethering among mitral valve prolapse (MVP) patients, and thus to further identify and characterize an MVP with pathological leaflet tethering (MVPt+) phenotype. Methods We prospectively evaluated 94 consecutive MVP patients with significant mitral regurgitation (MR) and 20 healthy controls. MVPt+ group was defined as tenting volume index (TVi) > 0.7 ml/m 2. The three-dimensional (3D) geometry of mitral valve apparatus and VCA was measured with dedicated quantification software. Results Of the 94 patients with MVP and significant MR, 31 patients showed a TVi > 0.7 ml/m 2 and entered the MVP with leaflet tethering (MVPt+) group. In stepwise multivariate analysis, only prolapse volume index and TVi was independently associated with 3D VCA. Apart from marked left ventricular and annular enlargement, MVPt+ group presented significantly higher frequency of leaflet flail, greater VCA, elevated plasma levels of NT-proBNP and sPAP. ROC curve revealed that occurrence of leaflet tethering is associated with a VCA ≥0.55 cm 2 in MVP patients. Conclusions Secondary leaflet tethering is a significant mechanism behind severe degenerative mitral regurgitation, resulting an MVPt+ phenotype featuring more advanced morphological and hemodynamical characteristics .
Left atrial (LA) dilatation is a powerful predictor of cardiovascular morbidity and mortality. LA longitudinal strain parameters evaluating reservoir, conduit and contractile strain can represent LA functions. We investigated the association between LA strain and left ventricular (LV) functions using speckle-tracking echocardiography in children with mitral regurgitation in 45 asymptomatic mitral regurgitation patients graded as mild, moderate and severe. LV strain was lower in the moderate group (–17.8±3.7%) and further reduced in the severe regurgitation group (-16±2.14%) in comparison with the reference group (-20.5±6.2%). Regarding LA functions, reservoir strain was higher in the severe and moderate mitral regurgitation groups (38±12.9% and 40.7±9.5%, respectively) in comparison with the controls (40.0±7.2%; p<0.0001). A milder depression of contraction was observed in the severe group (12.2%) than in the moderate group (13±7.2%). In the moderate and severe groups, LV strain correlated significantly with the vena contracta (r=–0.858; p=0.04). Vena contracta was the only independent association for LV longitudinal strain. ROC curve analysis predicted LV longitudinal strain as shown by vena contracta, with a cut-off value >5.65 mm. Vena contracta had a positive predictive value of 75% for predicting LV function. We propose the use of LA and ventricular strain during the follow-up of asymptomatic children with mitral regurgitation. Also, a vena contracta diameter of >5.6 mm can be used as a threshold for LV function impairment.
Background. Two-dimensional speckle tracking evaluation (2D-STE) is a useful tool to evaluate the complexity of atrial function by the analysis of the different phases of atrial deformation and by the combination with Doppler measurements of diastolic function. Aim of the study. To evaluate the role of the left atrial (LA) strain parameters to predict worsening chronic heart failure (CHF). Methods. We enrolled outpatients affected by CHF referred to our heart failure unit. Each patient underwent a medical visit, an electrocardiogram (ECG), and an echocardiographic examination. LA function was assessed by 2D-STE. The three phases of LA strain – i.e. the reservoir (LAr), the conduit (LAcd), and the contraction (LAct) – were evaluated. Moreover, the ratio between LAr and that of septal (LAr/Ees), lateral (LAr/Eel), and septal-lateral (LAr/Eem) E/e’ were evaluated. During follow-up, the worsening of heart failure was evaluated. Results. Two hundred twenty-eight patients were enrolled. During a mean follow-up of 14±7 months, 47 patients showed at least one event related to heart failure worsening (40 hospitalisations, 5 heart transplantations, and 19 cardiovascular deaths). During univariate Cox regression analysis, LAr, LAcd, LAct, LAr/Ees, LAr/Eel, and LAr/Eem were all associated with events related to heart failure worsening, but during multivariate regression analysis, only LAr (HR: 0.94; 95% CI: 0.91–0.98; p: 0.007), LAr/Ees (HR: 0.49; 95% CI: 0.30–0.78; p: 0.002), and LAr/Eem (HR: 0.65; 95% CI: 0.47–0.89; p: 0.008) remained significantly associated with the events. Finally, LASr/Ee’s showed accuracy in predicting outcomes greater than LASr (C-index 0.78 vs. 0.72, respectively). Conclusions. In CHF patients, the measure of the LA reservoir by 2D-STE is independently associated with heart failure worsening, but the accuracy in predicting the events is even greater when the reservoir is combined with the Doppler measures of diastolic function.
Half of patients with heart failure are presented with preserved ejection fraction (HFpEF). The pathophysiology of these patients is complex but increased left ventricular (LV) stiffness is proved to play a key role. However, the application of this parameter was limited since its measurements requires invasive catheterization. With advances in ultrasound technology, new advances have been achieved in the assessment of LV chamber or myocardial stiffness using noninvasive echocardiography. Therefore, this review was carried out to summarize the pathophysiological mechanisms, correlations with invasive LV stiffness constant, applications in different populations as well as the limitations of echocardiography-derived indices for assessment of both LV chamber and myocardial stiffness. LV chamber stiffness indices such as E/e’/LVEDV, E/SRe/LVEDV, and DPVQ were derived on the basis of the relationship between echocardiographic parameters of LVFP and LV size. However, all these methods are surrogate and lumped measurements, relying on E/e’ or E/SRe for evaluating LVFP. The limitations of E/e’ or E/SRe in assessment of LVFP may contribute to the moderate correlation between E/e’/LVEDV or E/SRe/LVEDV and LV stiffness constant. Even the best validated measurement (DPVQ) is considered unreliable in the individual patient. Compared to E/e’/LVEDV and E/SRe/LVEDV, I PVA/IA and F PVA/FA may display better performance in assessing LV chamber stiffness as evidenced by a higher correlation with LV stiffness constant. However, only one study has been conducted in the literature on the exploration and application of I PVA/I A and F PVA/F A, and its accuracy in assessing LV chamber stiffness remains to be confirmed. In terms of echocardiographic indices for LV myocardial stiffness evaluation, the parameters of EMI/DWS, iVP and SWI were proposed. Despite alteration of DWS and its predictive value of adverse outcomes in various populations have been widely validated, it was found that DWS may be better considered as an overall marker of cardiac function performance instead of pure myocardial stiffness. As for the iVP and SWI, the validities of these two indices in assessing LV myocardial stiffness have not been confirmed in invasive studies. More echocardiographic indices with higher sensitivities and specificities warrant to be further uncovered to evaluate LV stiffness.
A 16-year-old male with past medical history of congenital atrial septal defect surgical repair presented with recurrent pericarditis secondary to post-cardiotomy injury syndrome (PCIS). After failing medical therapy, he ultimately underwent pericardiectomy for symptom resolution. PCIS is underdiagnosed in children and should be considered in patients with recurrent chest pain.
Objective: Device lead-induced tricuspid regurgitation (LITR) mechanisms are well-defined by 3D transthoracic echocardiography (3D-TTE). There is a lack of data on the Latin-American population. The objective of this study was to describe the prevalence of several mechanisms and insights in patients with permanent right ventricular (RV) implanted devices by 3D-TTE examination. Methods: We performed a cross-sectional analysis of 101 patients with permanent cardiac devices such as pacemakers or defibrillators. 3D-TTE was obtained on all patients in RV-focused apical views to perform a complete tricuspid valve (TV) evaluation: leaflets, subvalvular apparatus, precise lead location, and functional assessment to evaluate possible mechanisms of tricuspid regurgitation (TR). Results: In a total of 101 patients, the leads did not interfere with TV function in 53 p. (59%), while LITR was observed in 38 (41%) patients. Adherent, impinging, entangled, and mixed lead-induced mechanisms were observed. Time in years since device implantation was significantly higher in patients with LITR. Conclusions: LITR was present in a high proportion of our population. LITR is the result of damage to the TV as well as its subvalvular apparatus due to the fibrotic and inflammatory response over time when leads are situated in unfavorable locations.
Background: As the volume of cardiac imaging continues to increase, so is the number of tests performed for rarely appropriate indications. Appropriate use criteria (AUC) documents were published by professional societies with quality improvement (QI) interventions developed in various institutions. However, the effectiveness of these interventions has not been assessed in a systematic fashion. Methods: We performed a database search for studies reporting the association between cardiac imaging, AUC and QI. We selected studies assessing the effect of QI interventions on performance of rarely appropriate echocardiograms. The primary endpoint was reduction of rarely appropriate testing. Results: Nine studies with 22,070 patients met inclusion criteria. QI interventions resulted in statistically significant reduction in rarely appropriate tests (OR 0.52, 95% CI 0.41-0.66; p<0.01). The effects of QI interventions were analyzed over both the short (< 3 months) and long-term (> 3 months) post intervention (OR 0.62, 95% CI: 0.49-0.79; p<0.01 in the short term, and OR 0.47, 95% CI: 0.35-0.62; p<0.01 in the long term). Subgroup analysis of the type of intervention, classified as education tools or decision support tools showed both significantly reduced rarely appropriate testing (OR 0.54, 95% CI: 0.41-0.73; p<0.01; OR 0.47, 95% CI: 0.36-0.61; p<0.01). Adding a feedback tool did not change the effect compared to not using a feedback tool (OR 0.49 vs. 0.57, 95% CI: 0.36-0.68 vs. 0.39-0.84; p>0.05). Conclusion: QI interventions are associated with a significant reduction in performance of rarely appropriate echocardiography testing, the effects of which persist over time.
Background: Left ventricular ejection fraction (LVEF) has prognostic value and is used to guide medical treatment and device implantation. The preferred technique is two-dimensional echo (2DE), although three-dimensional echo (3DE) is more accurate when compared to cardiac magnetic resonance imaging. Our study evaluates the agreement between 2D and 3D LVEF and the potential clinical impact of disagreements. Methods: Participants ≥50 years were included from the Copenhagen City Heart Study. Means of difference (MD) between 2D and 3D volumes and LVEF were assessed, Cox regression models were used to estimate the association between 2D and 3D LVEF <40% and outcome. 3DE were used as reference. Results: In all 1606 participants were included. Median age was 65.4 (IQR: 57.89‒73.6) and 702 (43.7%) were males. Median follow-up was 5.5 (IQR: 4.72‒6.3) in which 102 (6.4%) died and 142 (8.8%) experienced a major adverse cardiovascular event (MACE) and 194 (12.1%) any cardiovascular event. The MD between 2D and 3D LVEF as the LV deteriorated the LV got (LVEF <40%, MD: -14.4 (-15.9 ‒ -13.0) vs. LVEF 40-49% -9.2 (-9.8 ‒ -8.7) vs. LVEF >50%, MD: -0.96 (-1.4 ‒ -0.51)). 3D LVEF <40% was significantly associated with all outcomes (2.85 (95% CI: 1.64‒4.95), (all-cause mortality), 2.71 (95% CI: 1.68‒4.36), (MACE) and 2.41 (95% CI: 1.68‒4.36) (any cardiovascular event). 2D LVEF <40% was only associated to MACE 2.69 (95% CI: 1.25‒5.77). 2DE misclassified (defined as ≥10 percentage units of difference between 2D and 3d LVEF) LVEFs in 508 (31.6%) of all exams. Conclusion: In this population study in low-risk subjects, only 3D LVEF was associated with excess mortality, whereas 2D LVEF was not.
Echocardiography is essential for diagnosing and assessing the severity of perioperative structural and/or functional heart disease. Yet, educational opportunities to better understand echocardiography-based cardiac anatomy remain limited by the two-dimensional display, lack of anatomic details, variability of heart models, and/or costs and global availability of training. 3D printing using data from patient CT or MRI datasets has been used for creating effective teaching materials, although often it is limited by the resolutions. In this report, we discuss the development of ultra-high resolution 3D printed human hearts using ex vivo microcomputed tomography (μCT) and describe its utility for teaching both basic and advanced recommended views by the American Society of Echocardiography.
Background. Coronary heart disease is a serious threat to people’s life and health, and timely intervention and treatment are important. This study aims to investigate the clinical value of the serum C-reactive protein/albumin ratio (CRP/ALB, CAR) and the neutrophil/lymphocyte ratio (NE/LY, NLR) in predicting the extent of coronary artery disease. Methods. A total of 649 patients hospitalized in the Department of Cardiology of the Second People’s Hospital of Hefei with coronary angiography from January 2019 to December 2021 were included for retrospective analysis. The coronary artery disease group (n=406) and the control group (n=243) were divided according to the angiographic findings. The coronary artery disease group was divided into a mild lesion group (GS <40, n=235) and a severe lesion group (GS 40, n = 171) according to the Gensini score (GS). Compare the differences in CAR and NLR between groups. Spearman analysis was used to test the correlation between CAR, NLR and GS, logistic regression analysis was used to screen independent influencing factors of coronary artery disease and severe coronary lesions, and the ROC curve was used to analyze the predictive value of CAR, NLR and the combination of both for multiple lesions in coronary arteries. Results. CAR and NLR were higher in the coronary artery disease group than in the control group, and CAR and NLR were higher in the group with severe coronary lesions than in the group with mild lesions (P < 0.05). Spearman correlation analysis showed that CAR and NLR were positively correlated with GS (r CAR = 0.519, P < 0.05; r NLR = 0.492, P < 0.05). ROC analysis showed that CAR, NLR and the combination of the two had predictive value for multiple coronary lesions. The predictive efficacy was higher when the two were combined than the individual indexes ( P < 0.05). Conclusion. CAR and NLR are independent predictors of the extent of coronary artery lesions and can be used for diagnosing and evaluating coronary heart disease.
Endomyocardial fibrosis (EMF) is a neglected disorder, which is predominant in tropical regions and characterized by fibrotic thickening of the endomyocardium of one or both ventricles, resulting in a restrictive cardiomyopathy (1). Although eosinophilia, infections, toxic agents, malnutrition and immunologic causes have been shown to be associated with EMF, the etiology remains controversial (2). We present a rare case of right ventricular EMF with atrial septal defect (ASD).
Background: Cervical squamous cell carcinoma is one of the most common malignant tumors in the clinic. It can metastasize to the lung, bone, and other organs. However, postoperative recurrence and metastasis to the tricuspid valve are infrequent. Case presentation: A 57-year-old female patient, which had an operation history of squamous carcinoma of the cervix(SCC) one year ago, was admitted to the hospital due to the cervical squamous cell carcinoma recurred and metastasized to the tricuspid anterior and septum’ ventricular surface and the chordae tendineae. The patient underwent surgery in our hospital.Then the positron emission tomography-computed tomography of postoperation revealed cervical squamous cell carcinoma metastasis. Histopathology revealed the squamous carcinoma of the cervix.Moreover, the cardiac tumor reappeared after four postoperation months. The postoperative patients did not receive regular chemotherapy. The short-term effect on the patients was not ideal. Conclusion: To achieve better treatment results, the multi-mode treatment strategy of surgery, medical treatment, and advanced diagnosis has a significant impact on the survival of these patients.
Left atrial dissection is a rare complication of cardiac surgery and percutaneous cardiac procedures. It is defined as a false blood-filled cavity or lumen from mitral annular area to the left atrial free wall or into the atrial septum thereby creating a new chamber with or without communications with the true left atrium . We have reviewed literature and describe a case where echocardiography led to early recognition of this rare entity.
Purpose: Peripartum cardiomyopathy (PPCM) is a rare complication of pregnancy manifesting with acute cardiac failure. Coronavirus Disease 2019 (COVID-19) can be complicated by cardiomyopathy, which can be difficult to differentiate from PPCM. The aim of this publication is to investigate different outcomes of cases with cardiomyopathy during pregnancy. Methods: Here, we report 4 peripartum cases with COVID-19 and acute cardiac failure due to cardiomyopathy. Moreover, to find previous similar cases, a comprehensive review on PPCM and COVID-19 associated cardiomyopathy was conducted in PubMed, Scopus, Embase, and Google Scholar. Results: Out of 4 cases we had, two cases deceased and one became a candidate for heart transplant. Despite advanced diagnostic approaches, differentiating COVID-19 associated cardiomyopathy from PPCM was challenging. According to the literature review, 7 cases with similar conditions were found. Conclusion: Pregnant women with COVID-19 may develop acute cardiac failure associated with PPCM or COVID-19 associated cardiomyopathy or both. This condition may be deadly due to rapid disease progression, atypical manifestations, and limited treatment options.