Introduction In the current literature, several studies show that pulmonary artery stiffness (PAS) is associated with right ventricular (RV) dysfunction, pulmonary arterial hypertension (PAH), and disease severity in patients with structural heart disease, human immunodeficiency virus (HIV), and chronic lung disease. Hence, in this study, we aimed to use PAS to show the early changes in the pulmonary vascular bed in patients with cirrhosis. Material and Methods In this prospective, cross-sectional study, 39 subjects who were being followed up with cirrhosis and 41 age- and sex-matched healthy participants were enrolled. For each case, the PAS value was calculated by dividing mean peak velocity of the pulmonary flow by the pulmonary flow acceleration time (PfAT). Results The measured PAS was 23.62 ± 5.87 (Hz/msn) in cirrhotic patients and 19.09 ± 4.16 (Hz/msn) in healthy subjects (p < 0.001). We found a positive statistical significance between PAS and systolic pulmonary arterial pressure (sPAP) (r = 0.378; p = 0.001). PAS was an independent predictor that was associated with cirrhosis disease according to multivariate logistic regression analysis (OR: 1.209; 95% CI: 1.059–1.381; p = 0.005). Conclusion Based on the study results, we consider that PAS may help in the early detection of changes in the pulmonary vascular bed, even if the RV function parameters or sPAP are within the normal range.

Pulmonary artery sling (PAS) and tracheal agenesis (TA) are both very rare diseases. Most of PAS are associated with tracheal bronchial malformations. However, PAS associated with TA have not yet been reported so far. Here, we report one case of PSA associated with TA diagnosed prenatally in our hospital. Due to the extremely low incidence of two diseases, physicians do not have sufficient understanding of these disease, prenatal ultrasound examination found that these kinds of diseases are very challenging and confusable. Prenatal ultrasound and MRI examination of pulmonary artery branches, trachea and esophagus will provide useful information. Improving the accuracy of prenatal fetal diagnosis is helpful for perinatal management and counseling.

In the current literature, we observed a tendency to describe normal values ​​of echocardiographic measurements by means of the Z-score. In fetal cardiology, these Z-score equations are still being established. Measurement of myocardial thickness is an important assessment especially in fetuses of diabetic pregnant women because of the risk of developing myocardial hypertrophy secondary to elevated maternal blood glucose levels. To determine the percentiles and to develop the Z-score equations of right and left ventricular lateral wall and interventricular septum measurements using two-dimensional echocardiography in normal fetuses between 24 and 34 weeks of gestation. This is a prospective cross-sectional study that was performed in single fetuses with normal heart and in non-diabetic pregnant women. Measurements of the lateral wall of the right and left ventricles and the interventricular septum were made. 873 pregnant women were included. We determined the percentiles of the measurements for each gestational age. The Z-score equation was developed for each of the measurements: right ventricular lateral wall measurement [RVLW = x - (- 1 + 0.109 * GI) / 0.4], left ventricle lateral wall measurement [LVLW = x - (- 1.366 + 0.12 * GI) / 0.43] and the interventricular septum in the four-chamber plane [IVS4ch = (x - (- 1,113+ 0.107 * IG) / 0.4] and the interventricular septum in the left ventricular outflow tract plane [IVSLVOT = (x - (-0.581 + 0.084 * GI) / 0.35]. The present study allowed to demonstrate the percentiles and the Z-score equations for each of the measures studied.

Background: Stress echocardiography (SE) is an established technique for assessment of coronary artery disease (CAD) which is difficult to perform and interpret. Left ventricular stroke volume (SV) is readily estimated with Doppler echocardiography. It can be affected by myocardial ischemia, with possible adjunctive value during SE. Methods: Patients underwent Bruce protocol SE with SV estimated before and after maximal treadmill exertion post routine regional wall analysis. Incremental change in SV (ΔSV) with exercise was measured. Results: A derivation cohort (n=273) was established to test the hypothesis. An optimal cut-off for detection on inducible ischemia was ΔSV ≤ +10ml. The validation cohort of consecutive patients (n = 1093, 376 [34%] female; age 59±12 years) were followed clinically after SE for 20,460 patient-months. There were 1000 patients with non-ischemic SE, and 93 patients with studies suggestive of myocardial ischemia. Secondary analysis yielded 831 patients with a normal exercise response (ΔSV > +10ml) and 192 with an abnormal ΔSV ≤ +10ml. Time to first combined adverse cardiac event (composite of angina, acute coronary syndrome, cardiac revascularization, worsening New York Heart Association (NYHA) class, a reduction in EF, and cardiovascular death) was analysed and adjusted using Cox proportional hazards regression. The hazard ratio for an adverse event with an abnormal ΔSV response (≤10ml) was 10.3 (95% confidence intervals 5.6-19.1, p<0.0001). Conclusions: SV assessment during SE is feasible and readily performed. It is simple, practical and has incremental diagnostic and prognostic value when added to exercise regional wall motion analysis.

Hypertrophic cardiomyopathy is a common heritable cardiomyopathy with various clinical phenotypes. A rare spiral variant has been recently reported that has been associated with adverse outcomes and has traditionally been diagnosed using cardiac magnetic resonance. We report a case of the rare variant spiral hypertrophic cardiomyopathy where we used transthoracic echocardiography with an ultrasound enhancing agent to demonstrate the geometry of spiral hypertrophic cardiomyopathy and compared to simultaneous cardiac MRI images. The use of echocardiography with ultrasound enhancing agents may prove to be a valuable tool in identifying the geometry of hypertrophic cardiomyopathy variants in selected patients.

Classical absent pulmonary valve syndrome (APVS) with tetralogy of Fallot (TOF) is a rare congenital cardiac anomaly commonly associated with absent of patent ductus arteriosus (PDA), which is mostly diagnosed after 20 weeks of gestation by fetal echocardiography. This case of APVS with TOF was suspected at 13 weeks of gestation and diagnosed at 14 weeks of gestation with an obvious PDA. The pulmonary arterial trunk and the branches did not dilated obviously. 15 days later, the PDA narrowed down with the discovery of pulmonary artery ectasia at the same time. This progress indicated that the absent of PDA is not necessary for the survival of APVS with TOF in utero, in contrast, the absent or restriction of PDA may be nothing less than adaptation to the disease. Fetal autopsy confirmed the accuracy of fetal echocardiography. Chromosome microarray analysis (CMA) showed 20p12 deletion in this fetus, which is rare among TOF cases.

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Purpose: The aim of this study was to evaluate right ventricle (RV) dyssynchrony and its relation with mortality using speckle tracking echocardiography (STE) in patients with acute inferior myocardial infarction (IMI). Methods: One hundred and fifty-eight consecutive patients with acute IMI treated with primary percutaneous coronary intervention and 44 healthy subjects were included. RV myocardial involvement (RVMI) was defined as an elevation greater than 1 mm in V1 or V4R and/or the presence of a culprit lesion at the proximal portion of the first RV marginal branch after reviewing coronary angiography. Patients were followed for three years to determine the cardiovascular mortality. Results: Overall, 70 patients with IMI had RVMI. IMI patients had significantly higher RV peak systolic longitudinal strain dyssynchrony (PLSSD) index, lower peak longitudinal systolic strain (PLSS), longer time to PLSS and time to PLSS differences compared to healthy controls while the patients with RVMI had significantly worse values compared to patients without RVMI and healthy controls. Twenty-seven patients (17.1%) died within two years. RVMI was more prevalent in mortality group and they had significantly higher RV PSSD index, whereas they had lower RV free wall PLSS and longer time to PLSS differences. ROC analysis revealed that a RV PLSSD index > 65 ms predicted mortality with a sensitivity of 88.9% and specificity of 71.8,% in IMI patients. Conclusions:Intra- and interventricular dyssynhcrony may develop in patients with acute IMI, especially in those with RV involvement, which might have a negative effect on the prognosis of these patients.

Despite advancement in therapy and management, left ventricular thrombus (LVT) after anterior myocardial infarction (MI) is sporadically encountered and remains associated with a very high risk of major cardiovascular events and mortality. Cardiac magnetic resonance (CMR) is considered the gold standard technique for LVT detection, but it is a time consuming and expensive test not available in all centers, especially when repeated exams are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT. The advances in ultrasound technology and the use of contrast agents may potentially help clinicians to identify LVT and the use of sequential echocardiography for each patient with acute MI complicated by LVT may provide an opportunity to quantify regression and its correlation with outcomes to tailor the management of these patients. Hence, this narrative review focuses on the added value of echocardiographic-guided LVT management in patients with recent anterior MI to reduce mortality and morbidity excess related to LVT based on current evidence.

Background: Although diastolic dysfunction is common among patients treated with cancer therapy, no clear evidence has been shown that it predicts systolic dysfunction. This study evaluated the correlation of longitudinal diastolic strain time (Dst) with the routine echocardiography diastolic parameters and to estimated its role in the early detection of cardiotoxicity among patients with active breast cancer. Methods: Data were collected as part of the Israel Cardio-Oncology Registry (ICOR), a prospective registry enrolling all adult patients referred to the cardio-oncology clinic. All patients with breast cancer, planned for Doxorubicin therapy were included. Echocardiography, including Global longitudinal systolic strain (GLS) and Dst, was assessed at baseline before chemotherapy (T1), during Doxorubicin therapy (T2) and after the completion of Doxorubicin therapy (T3). Cardiotoxicity were determined by GLS relative reduction of ≥15%. Dst was assessed as the time measured (ms) of the myocardium lengthening during diastole. =diastolic time (ms) measured. Results: Among 69 patients, 67 (97.1%) were females with a mean age 52±13years. Diastolic strain timeDst measurement was significantly associated with the standard routine diastolic parameters. Significant GLS reduction was observed in 10 (20%) patients at T3 . Both in a univariate and a multivariate analyses the change in Ds basal time from T1 to T2 emerged to be significantly associated with GLS reduction at T3 (p<0.04). Conclusions: Among breast cancer patients, Dst time showed high correlation to standard the routine diastolic echocardiography parameters. Relative reductionChange in Ds basal time emerged associated with clinically significant systolic dysfunction as measured by GLS reduction.

Background: Right ventricular failure (RVF) following Left Ventricular Assist Device (LVAD) implantation is associated with worse outcomes. Prediction and early identification of RVF with speckle-tracking echocardiography (STE) has been proposed. Methods: We queried multiple databases for articles reporting on pre-operative/intraoperative global longitudinal strain (GLS) and free-wall strain (FWS) in LVAD recipients. We performed a systematic review and meta-analysis of published literature. The standard mean difference (SMD) in GLS and FWS in patients with and without RVF postoperatively was pooled using random effects model. Results: Fifteen studies, with a total of 967 LVAD recipients were included. There was statistically significant difference in GLS among patients who did and did not develop RVF; SMD= -3.09 (95% CI: -4.62 to -1.57; p-value <0.0001). There was significant difference in FWS between two groups; SMD: -2.75 (95% CI: -3.72 to -1.79; p-value <0.0001). Upon subgroup analysis of imaging modality, transthoracic echocardiography (TTE)-derived GLS and FWS remained predictive for RVF with SMD of -3.97 (95% CI: -5.40 to -2.54; p-value <0.001) and -3.05 (95% CI: -4.11 to -1.99; p-value <0.001), respectively. However, there was no significant difference between RVF and non-RVF groups upon using transesophageal echocardiography (TEE) to assess GLS and FWS. Conclusion: GLS and FWS assessment of the RV by STE is a useful tool to predict postoperative RVF in LVAD recipients. While the predictive role of TTE was robust, the TEE-derived measures seemed to be less predictive. Future studies need to specify the strain cut-off value that can predict the adverse outcome of RVF

Our case was initially admitted with presumptive diagnosis of Non-ST elevated myocardial infarction in congestive heart failure and was later found to have large left atrial (LA) mass. Apart from complete echocardiography study, we took help of multimodality imaging to better characterise this LA mass.However we did not have a confirmed diagnosis. Cardiac surgery was performed and surprisingly revealed large LA mass with pockets of fresh blood inside LA. Pathological specimen confirmed the presence of hematoma ruling out other atrial neoplasms. Though contrast echocardiography and cardiac magnetic resonance imaging were closest to intra-operative diagnoses, In the absence of any pre-disposing factors, final diagnosis was made at surgery and histopathological diagnosis.

Diagnosis of anomalous origin of the right subclavian artery (AORSA) from the right pulmonary artery (RPA) is usually made using CT or invasive angiography. We report a patient diagnosed using transthoracic echocardiography (TTE). A newborn girl prenatally known to have d-TGA presented with cyanosis sparing the right hemithorax and arm. Oxygen saturations on the right hand were persistently higher than on the right ear and other extremities. Repeat TTE using a modified echocardiographic imaging plane allowed for full visualization of the entire subclavian artery course, revealing AORSA from RPA. We discuss further the approach to echocardiographic diagnosis and surgical implications.

Objective: To evaluate the role of peak atrial longitudinal strain (PALS) through speckle tracking 2D echocardiography for the assessment of structural and functional left atrial (LA) remodelling in a type 2 diabetes mellitus (T2DM) population. Methodology: We conducted a cross-sectional study during a 9-month period. Were included T2DM adults aged 18 and above. The variables assessed during the study include age and gender of participants, diabetes characteristics, cardiovascular risk factors, clinical anthropometric and haemodynamic parameters, standard echocardiographic parameters, volume-derived LA functions and 2D PALS. Results: We included a total of 102 patients. The mean age was 58±11.7 years and the M/F sex ratio was 1:1.5. Coexistent arterial hypertension (HTN) was observed in more than half (59.8%) of the population sample. Mean 2D PALS was 29.2±8.9% with 58.8% (95% CI:50.0–68.6) of subjects having a reduced LA strain (i.e.<32%). Reservoir and pump functions were the most altered LA volumetric phasic functions. Mean indexed LA maximal volume was 22.2±6.8 ml/m². There was a significant association between abnormal PALS and age, Body mass index (BMI), indexed LA volume, E/E’ ratio, LA active ejection fraction (pump function) and LA expansion index (reservoir function). Conclusion: LA remodelling is a recurrent condition in adult T2DM Cameroonians. The Reservoir and pump LA functions were the most affected. Assessment of LA global strain allows early detection of LA remodelling with comparison to LA size standard analyses. Age, BMI, indexed LA volume, E/E’ ratio, reservoir and pump LA functions were associated to 2D LA global strain impairment.

Introduction: The right ventricle (RV) strain measured by speckle tracking (RVS) is a novel method of assessing RV function. We compared RVS to RV fractional area change (FAC%), tricuspid annular peak systolic excursion (TAPSE) and Doppler tissue imaging-derived peak systolic velocity (S’) in the assessment of right ventricular (RV) systolic function measured using cardiac magnetic resonance imaging (MRI). Methods: We enrolled consecutive patients who underwent cardiac MRI between Jan 2012- Dec 2017 and a transthoracic echocardiogram (TTE) within 1 month of the MRI with no interval event. Baseline clinical characteristics and MRI parameters were extracted from chart review. Echocardiographic parameters were measured prospectively. TTE parameters including RVS, TAPSE, S’ and FAC% were tested for accuracy to identify impaired RV EF (EF <45% & <30%) using receiver operator curves. Results: The study cohort included 500 patients with mean age 55 yr ± 18 and right ventricular systolic pressure 33.7 ± 13.6 mmHg. The area under ROC for RVS was 0.69 (95% CI 0.63 – 0.75) and 0.78 (95% CI 0.70 – 0.88) to predict RVEF <45% & RVEF <30% respectively. The RV FAC % had second highest accuracy of predicting RVEF among all the TTE parameters tested in study. Conclusion: Right ventricular strain is the most accurate echocardiographic method to detect impaired right ventricular systolic function when using MRI as the gold standard.

We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days post-discharge (i.e. 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.

Correlation between AHI and right ventricular diastolic function in patients with obstructive sleep apnea syndromeJunfang Li 1, MD, PhD, Changhong Lu2, MD, Zhibin Wang 1, MD, PhD1, Department of Echocardiography, Qingdao University Affiliated Hospital, Qingdao, 266001,China2, Department of Heart Center, Qingdao Fuwai Cardiovascular Hospital, Qingdao, 266034,ChinaCorresponding author: Zhibin Wang, Department of Echocardiography, Qingdao UniversityAffiliated Hospital, No. 16, Jiangsu Road, Qingdao 266001, China

Aim Doppler echocardiography has become the standard imaging modality for diastolic function and provide pathophysiological insight into systolic and diastolic heart failure. In this study we aimed to obtain normal echocardiographic Doppler parameters of healthy Turkish population. Methods Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination and The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used for echocardiographic Doppler measurements. Results A total of 967 healthy participants were enrolled in this study after applying exclusion criteria. Echocardiographic examination was obtained from all subjects following predefined protocols. Mitral E wave velocity and E/A ratio were higher in females and decreased progressively in advancing ages. E wave deceleration time and A wave velocity were increased with aging. Assessment of tissue Doppler velocities showed that left ventricular lateral e’, septal e’ and septal s’ were higher in younger subjects and in females. E/e’ ratio was increased progressively with advancing decades. Right ventricular e’and s’ were decreased but a’ was increased with increasing age. Septal e’ lower than 8 cm/s was 1.9% in the fifth decade and 13.7% in ages older than 50-years. The E/e’ ratio greater than 15 (and also 13) was not found. Conclusion This study, for the first time, provides echocardiographic reference ranges for normal cardiac Doppler data in healthy Turkish population which will be useful in routine clinical practice as well as in future clinical trials.