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.

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.

Aim:This study aims to investigate the effects of maternal asthma on fetal cardiac functions. Methods:The study was planned with 30 pregnant women who presented to a tertiary health center and were diagnosed with asthma and 60 healthy controls with similar gestational ages. The fetal echocardiographic assessment was assessed between 33 and 35 weeks of gestation with pulsed-wave Doppler (PW), M-mode, and tissue Doppler imaging (TDI). Fetal cardiac functions were compared between maternal asthma and control group. Cardiac functions were assessed according to the duration of maternal asthma diagnosis, as well. Results:Early diastolic function parameters, tricuspid E wave (p=0.001), and tricuspid E/A ratio (P=0.005) were significantly lower in the group with maternal asthma. TAPSE and MAPSE values were statistically lower in the study group than in the control group; p=0.010 and p=0.012, respectively. Parameters assessed with TDI (E’, A’, S’, E/E’, and MPI’ of tricuspid valves) and global cardiac function parameters assessed with pulsed-wave Doppler like myocardial performance index (MPI) and left cardiac output (LCO) were similar between groups (p> 0.05). Although, MPI did not change between groups, and the isovolumetric relaxation time (IVRT) value was prolonged in maternal asthma cases (p=0.025). Conclusion:We found that maternal asthma disease causes alteration in fetal diastolic and early systolic cardiac functions, but the global fetal cardiac function does not change. Diastolic heart function values also varied with the duration of maternal asthma. Prospective studies are needed to compare fetal cardiac functions with additional patient groups according to disease severity and type of medical treatment.

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: For severe mitral valve (MV) degenerative disease, repair is recommended. Prediction of repair complexity and referral to centers of excellence can increase rates of successful repair. This study sought to demonstrate that TEE is a feasible imaging modality to predict the surgical MV complexity score previously developed by Anyanwu et al. Methods: Two hundred TEE examinations of patients who underwent MV repair (2009 – 2011) were retrospectively reviewed and scored by two cardiac anesthesiologists. TEE scores were compared to surgical complexity scores of same subset of patients. Kappa values were reported for the agreement of TEE and surgical scores. McNemar’s tests were used to test the homogeneity of the marginal probabilities of different scoring categories. Results: TEE scores were slightly lower (2[1,3]) than surgical scores (3[1,4]). Agreement was 66% between the scoring methods, with a moderate kappa (0.46). Using surgical scores as the gold standard, 70%, 71% and 46% of simple, intermediate and complex surgical scores, respectively, were correctly scored by TEE. P1, P2, P3, and A2 prolapse were easiest to identify with TEE and had the highest agreement with surgical scoring (P1 agreement 79% with kappa 0.55, P2 96% (kappa 0.8), P3 77% (kappa 0.51), A2 88% (kappa 0.6)). The lowest agreement between the two scores occurred with A1 prolapse (kappa 0.05) and posteromedial commissure prolapse (kappa 0.14) (Figure 3). In the presence of significant disagreement, TEE scores were more likely to be of higher complexity than surgical. McNemar’s test was significant for prolapse of P1 (p=0.005), A1 (p=0.025), A2 (p=0.041), and the posteromedial commissure (p<.0001).

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.

Bicuspid aortic valve is the most common congenital cause for the development of aortic valve calcification and stenosis. Calcification cause valvular stenosis or valvular insufficiency due to coaptation failure. We report a unique case of calcification of bicuspid valve was extending to left ventricular outflow tract and attached to interventricular septum which caused subvalvular stenosis.

Pneumopericardium is the presence of air in the pericardial sac. Pneumopericardium after pericardiocentesis has been rarely reported in the literature. In the present case, we report a patient who presented with tamponade physiology during COVID-19 and developed pneumopericardium after emergency pericardiocentesis. Immediate recognition and treatment are crucial and chest X-ray, thorax computerized tomography and transthoracic echocardiography are used for diagnosis.

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: Prolonged endurance exercise is associated with an increased risk of atrial fibrillation (AF) in men. Left atrial (LA) dilation is a marker of pathological atrial remodeling and associated with AF in the general population. In athletes, however, atrial dilation is part of a physiological response to exercise, and functional parameters may help separate physiological from pathological atrial remodeling in this group. LA mechanical dispersion (LA MD) is a novel marker of LA mechanical dyssynchrony associated with AF in the general population. The associations between prolonged endurance exercise, LA MD and AF are yet to be investigated. Purpose: To investigate LA MD in male veteran athletes who had regularly participated in an annual 54-kilometer cross-country (XC) ski race in Norway with and without paroxysmal AF and to investigate the ability of LA MD to identify veteran athletes with paroxysmal AF. Methods: Two hundred and ninety-three men from four groups, veteran XC skiers with (n=57) and without (n=87) AF, and men from a non-athletic population with (n=61) and without AF (n=88) underwent an echocardiographic exam while in sinus rhythm. Using speckle-tracking echocardiography, LA strain was measured in each of the six atrial segments in an atrial-focused apical four-chamber view. We defined LA MD as the standard deviation of time-to-peak strain (SD-TPS) and report the average from three consecutive loops. Results: XC-skiers (mean age 70.9 ± 5.7 years) reported an average of 40-50 years of regular endurance exercise and an average of 16 completed annual Birkebeiner XC ski races. LA volumes were associated with both AF and athletic status (p<0.001). SD-TPS was associated with AF (p<0.001), but not with athletic status (p=0.173). We found no significant trend between years of endurance exercise and SD-TPS in individuals without AF (p=0.846). SD-TPS did not add incremental value in identifying athletes with AF in addition to clinical markers, QRS width, LA volume, and LA reservoir strain (p=0.056). Conclusion: LA MD was associated with paroxysmal AF regardless of athletic status. However, it was not associated with years of performing endurance exercise, suggesting LA MD could be a promising marker of pathological atrial remodeling in endurance athletes, less affected by physiological exercise-induced atrial remodeling than absolute volumetric measurements. We found no incremental value of LA MD in identifying veteran athletes with paroxysmal AF when LA reservoir strain was included in the model.

A document by Tasneem Naqvi. Click on the document to view its contents.

Aim. To investigate abnormalities in myocardial strain and classic echocardiographic indices and coronary flow reserve (CFR), in younger vs older CKD patients. Methods. Sixty consecutive CKD patients (<60 years old n=30, ≥60 years old n=30) and 30 healthy controls (age- and gender-matched with younger CKD patients) were recruited. An echocardiographic assessment including myocardial strain indices was performed at baseline and following dipyridamole administration in all participants. Results. Younger CKD patients had higher E/e’, left ventricular mass index and relative wall thickness and lower E’ (p<0.005 for all) compared to healthy controls. Older CKD patients had lower E/A and E’ (p<0.05 for both) compared to younger CKD patients; these differences did not remain significant after adjustment for age. CFR was higher in healthy controls compared to younger and older CKD patients (p<0.05 for both) without a significant difference between CKD groups. Dipyridamole-induced changes did not differ significantly among the 3 groups. Conclusions. Compared to healthy controls, impaired coronary microcirculation and left ventricular diastolic function, but not myocardial strain abnormalities, are found in young CKD patients and deteriorate with aging.

Objectives: Data on intraoperative three-dimensional derived right ventricular free-wall strain (3D-RV FWS) is sparse. We sought to evaluate the normal range of intraoperative 3D-RV FWS in patients scheduled for coronary artery bypass graft (CABG) surgery and compare to conventional echocardiographic parameters. Design: Prospective observational study. Setting: Single university hospital. Participants: 150 patients with preserved left and right ventricular function and sinus rhythm, without significant heart valve disease or pulmonary hypertension undergoing isolated onpump CABG surgery, with an uneventful, complication-free intraoperative course. Interventions: 3D-RV FWS analysis and conventional echocardiographic assessment of right ventricular function were performed intraoperatively in anesthetized and ventilated patients using transesophageal echocardiography (TEE). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support or pacing. Measurements and Main Results: We used TomTec 4D RV-Function 2.0 software for assessment of 3D-RV FWS and three-dimensional right ventricular ejection fraction (3D-RV EF). Philips QLAB 10.8 was used to evaluate tissue velocity of the tricuspid annulus (RV S´), tricuspid annular systolic excursion (TAPSE), and RV fractional area change (FAC). Assessment of 3D-RV FWS was feasible in 95% of patients. No included patient experienced a serious perioperative complication. In our group of patients, median values with interquartile range (IQR) for 3D-RV FWS and 3D-RV EF were - 25.2 (IQR -29.9 - -21.8) and 46.3% (IQR 41.0 - 50.1%), respectively. RV FAC, RV S´ and TAPSE accounted for 39.7% (IQR 34.5 - 44.4%), 14.8cm/s (IQR 11.8 - 19.0cm/s) and 22 mm (IQR 20-25mm). Normal range (2.5% to 97.5% percentile) for 3D-RV FWS was -37.1 to -12.8. There was no relevant correlation of 3D-RV FWS to postoperative outcome in this group of CABG patients. Conclusion: We present distribution values for intraoperative 3D-RV FWS and conventional parameters of RV function assessment in a healthy on-pump CABG patient population without serious perioperative complications. We observed no correlations of these parameters with any of the outcome parameters considered. Therefore, we consider these values to be intraoperative TEE-assessed normal values that can be expected in onpump CABG patients.

Background Left ventricular (LV) systolic and diastolic functions are important cardiovascular risk predictors in patients with hypertension. However, data on segmental, layer-specific strain, and diastolic strain rates in these patients are limited. The aim of this study was to investigate segmental two-dimensional strain rate imaging (SRI)-derived parameters to characterize LV systolic and diastolic function in hypertensive individuals compared with that in normotensive individuals. Methods The study sample comprised 1194 participants from population studies in Arkhangelsk and Novosibirsk, Russia, and 1013 individuals from the Seventh Tromsø Study in Norway. The study population was divided into four subgroups: A. healthy individuals with normal blood pressure (BP), B. individuals on antihypertensive medication with normal BP, C. individuals with systolic BP 140–159 mmHg and/or diastolic BP >90 mm HG, and D. individuals with systolic BP ≥160 mmHg. In addition to conventional echocardiographic parameters, global and segmental layer-specific strains and strain rates in early diastole and atrial contraction (SR E, SR A) were extracted. The strain and SR (S/SR) analysis included only segments without strain curve artifacts. Results With increasing BP, the systolic and diastolic global and segmental S/SR gradually decreased. SR E, a marker of impaired relaxation, showed the most distinctive differences between the groups. In normotensive controls and the three hypertension groups, all segmental parameters displayed apico-basal gradients, with the lowest S/SR in the basal septal and highest in apical segments. Only SR A did not differ between the segmental groups but increased gradually with increasing BP. End-systolic strain showed incremental epi-towards endocardial gradients, irrespective of the study group. Conclusion Arterial hypertension reduces global and segmental systolic and diastolic left ventricular S/SR parameters. Impaired relaxation determined by SR E is the dominant factor of diastolic dysfunction, whereas end-diastolic compliance (by SR A) does not seem to be influenced by different degrees of hypertension. Segmental strain, SR E and SR A provide new insights into the LV cardiomechanics in hypertensive hearts.

A giant ascending aortic aneurysm associated with a ruptured sinus of Valsalva is rare. A 53-year-old male patient successfully underwent Bentall procedure after multimodality imaging which enable the correct diagnosis to be established and intraoperative transesophageal echocardiography provides additional information on the surgical planning.

Background: Left atrial appendage occlusion (LAAO) in the treatment of atrial fibrillation (AF) has become a hot topic in clinical research in recent years. Case presentation: we report a 68-year-old female patient who was admitted for “recurrent palpitations for three years,” with an electrocardiogram finding of atrial fibrillation (Figure [1](#fig-cap-0001)). The diagnosis upon admission was: (1) arrhythmia: paroxysmal AF (CHA2DS2-VASc: 4 points, HAS-BLED: 3 points), (2) Grade 3 hypertension, and (3) carotid plaque with internal carotid artery stenosis. The patient had a history of AF for three years with poor drug treatment effect. The patient was unable to tolerate anticoagulation therapy. We gave the patient a one-stop procedure treatment of “AF radiofrequency ablation + LAAO” under the guidance of 3D printing technology. There was no recurrence of AF or paravalvular leakage at the three-month and one-year follow-ups. Conclusions: The 3D printing technology guide the one-stop operation of “AF radiofrequency ablation + LAAO” is helpful. But it whether can improve the prognosis and quality of life of patients, further multi-center research and large data statistics are required.

Background: In low-income nations, Rheumatic valvular heart disease remains a major cause of morbidity and premature deaths. Accurate prevalence data in Egypt are still lacking yet highly desirable to facilitate health care planning. Methodology: An cluster sample of school children in eastern Egyptian Governorates was examined clinically and echocardiographically (using abbreviated protocol) for detection of rheumatic valvular heart disease based on 2012 World Heart Federation criteria (the Doppler and the morphological criteria) for diagnosis. According to echocardiography interpretation, participants were categorized as having definite RHD, borderline RHD or no RHD. Results: A total A total of 1680 students aged between 6 and 18 years were screened, 119 echocardiographic studies were non-interpretable; so, a total of 1560 studies were evaluated. From the total screened students, 1560 studies were adequate and interpretable according to the criteria specified in the methods section. This revealed a prevalence of 2.3% of the sample with RHD without adding the equivocal cases. The most prevalent lesion as detected by echocardiography was mitral regurgitation (29% of definite RHD cases). Conclusion: Rheumatic valvular heart disease remains prevalent in Egypt and the findings of this study should influence early detection, primary and secondary prevention, and adequate future national health plans.

Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve or, less frequently, the left ventricular outflow tract. We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.