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1. Blood Stasis Imaging Predicts Cerebral Microembolism during Acute Myocardial Infarction

   Publication date: Available online 5 December 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Antonia Delgado-Montero, Pablo Martinez-Legazpi, M. Mar Desco, Daniel Rodríguez-Pérez, Fernando Díaz-Otero, Lorenzo Rossini, Candelas Pérez del Villar, Elena Rodríguez-González, Christian Chazo, Yolanda Benito, Oscar Flores, José Carlos Antoranz, Francisco Fernández-Avilés, Juan C. del Álamo, Javier Bermejo

   Background

   Cardioembolic stroke is a major source of mortality and disability worldwide. The authors hypothesized that quantitative characterization of intracardiac blood stasis may be useful to determine cardioembolic risk in order to personalize anticoagulation therapy. The aim of this study was to assess the relationship between image-based metrics of blood stasis in the left ventricle and brain microembolism, a surrogate marker of cardiac embolism, in a controlled animal experimental model of acute myocardial infarction (AMI).

   Methods

   Intraventricular blood stasis maps were derived from conventional color Doppler echocardiography in 10 pigs during anterior AMI induced by sequential ligation of the mid and proximal left anterior descending coronary artery (AMI-1 and AMI-2 phases). From these maps, indices of global and local blood stasis were calculated, such as the average residence time and the size and ratio of contact with the endocardium of blood regions with long residence times. The incidence of brain microemboli (high-intensity transient signals [HITS]) was monitored using carotid Doppler ultrasound.

   Results

   HITS were detected in 0%, 50%, and 90% of the animals at baseline and during AMI-1 and AMI-2 phases, respectively. The average residence time of blood in the left ventricle increased in parallel. The residence time performed well to predict microemboli (C-index = 0.89, 95% CI, 0.75–1.00) and closely correlated with the number of HITS (R = 0.87, P < .001). Multivariate and mediation analyses demonstrated that the number of HITS during AMI phases was best explained by stasis. Among conventional echocardiographic variables, only apical wall motion score weakly correlated with the number of HITS (R = 0.3, P = .04). Mural thrombosis in the left ventricle was ruled out in all animals.

   Conclusions

   The degree of stasis of blood in the left ventricle caused by AMI is closely related to the incidence of brain microembolism. Therefore, stasis imaging is a promising tool for a patient-specific assessment of cardioembolic risk.

2. The Impact of Distinct Exercise Training Modalities on Echocardiographic Measurements in Patients with Heart Failure with Reduced Ejection Fraction

   Publication date: Available online 4 December 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Nick S.R. Lan, Kaitlyn Lam, Louise H. Naylor, Daniel J. Green, Novia S. Minaee, Peter Dias, Andrew J. Maiorana

   Background

   Exercise training is an important component of multidisciplinary heart failure management. However, the effects of aerobic training (AT) versus resistance training (RT) on cardiac function in patients with heart failure with reduced ejection fraction are not well defined. The aim of this study was to evaluate the impact of these exercise modalities on echocardiographic parameters.

   Methods

   Participants with stable heart failure with reduced ejection fraction (ejection fraction < 50%) were randomized to 12 weeks of AT, RT, or untrained control. Exercise was performed at matched relative intensities of each training modality (50%–70% of maximum). Echocardiography and cardiopulmonary exercise testing were performed at baseline and after 12 weeks of training.

   Results

   Thirty-eight participants were randomized, and 12 in each group completed the intervention (mean age, 61.5 ± 1.7 years; 89% men). Peak oxygen consumption increased from 14.5 ± 1.3 to 17.2 ± 1.6 ml · min⁻¹ · kg⁻¹ after AT and from 13.7 ± 1.2 to 16.4 ± 1.1 ml · min⁻¹ · kg⁻¹ after RT (P < .001 for both). In the AT group, there was a decrease in septal e′ (from 0.052 ± 0.004 to 0.041 ± 0.004 m/sec) and increases in E/e′ ratio (from 18.2 ± 3.1 to 23.8 ± 3.5), left atrial volume (from 86 ± 9 to 99 ± 10 mL), and right ventricular end-diastolic area (from 18 ± 1 to 20 ± 1 cm²; P < .05 for all), but these were unchanged in the control and RT groups. There were no significant changes in left ventricular diameters or volumes or right ventricular fractional area change after exercise.

   Conclusions

   There is a differential effect of AT versus RT on some echocardiographic parameters in patients with heart failure with reduced ejection fraction. AT was associated with evidence of worsening myocardial diastolic function, whereas this was not apparent after RT. Further studies are indicated to investigate the long-term clinical significance of these adaptations.

3. Therapeutic Ultrasound Improves Myocardial Blood Flow and Reduces Infarct Size in a Canine Model of Coronary Microthromboembolism

   Publication date: Available online 4 December 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Mrinal Yadava, D. Elizabeth Le, Igor V. Dykan, Marjorie R. Grafe, Matthew Nugent, Azzdine Y. Ammi, David Giraud, Yan Zhao, Jessica Minnier, Sanjiv Kaul

   Background

   Therapeutic ultrasound (TUS) has been used to lyse infarct-related coronary artery thrombus. There has been no study examining the effect of TUS specifically on myocardial microthromboemboli seen in acute myocardial infarction and acute coronary syndromes. The aim of this study was to test the hypothesis that TUS improves myocardial blood flow (MBF) and reduces infarct size (IS) in this situation by dissolving myocardial microthrombi.

   Methods

   An open-chest canine model of myocardial microthromboembolism was created by disrupting a thrombus in the left anterior descending coronary artery, and 1.05- and 0.25-MHz TUS (n = 7 each) delivered epicardially for 30 min was compared with control (n = 6). MBF and IS (as a percentage of left anterior descending coronary artery perfusion bed size) were measured 60 min after treatment. In addition, immunohistochemistry was performed to assess microthrombi, and histopathology was performed to define inflammation.

   Results

   Transmural, epicardial, and endocardial myocardial blood volume and MBF (measured using myocardial contrast echocardiography) and percentage wall thickening were significantly higher 60 min after receiving TUS compared with control. The ratio of IS to left anterior descending coronary artery perfusion bed size was significantly smaller (P = .03) in the 1.05-MHz TUS group (0.14 ± 0.04) compared with the control (0.31 ± 0.06, P = .04) and 0.25-MHz (0.36 ± 0.08) groups. MBF versus percentage wall thickening exhibited a linear relation (r = 0.65) in the control and 1.05-MHz TUS groups but not in the 0.25-MHz TUS group (r = 0.29). The presence of myocardial microemboli in vessels >10 μm in diameter was significantly reduced in the 1.05-MHz TUS group compared with the other two groups. The distribution and intensity of inflammation was higher in the 0.25-MHz TUS group compared with the other groups.

   Conclusions

   TUS at 1.05 MHz is effective in restoring myocardial blood volume and MBF, thus reducing IS by clearing the microcirculation of microthrombi. IS reduction is not seen at 0.25 MHz, despite improvement in MBF, which may be related to the increased inflammation noted at this frequency. Because both acute myocardial infarction and acute coronary syndromes are associated with microthromboembolism, these results suggest that TUS could have a potential adjunctive role in the treatment of both conditions.

4. Cardiac Remodeling in Middle-Aged Endurance Athletes and Recreationally Active Individuals: Challenges in Defining the “Athlete's Heart”

   Publication date: Available online 4 December 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Laura Banks, Robert F. Bentley, Katharine D. Currie, Emily Vecchiarelli, Arfa Aslam, Kim A. Connelly, Andrew T. Yan, Kaja M. Konieczny, Paul Dorian, Susanna Mak, Zion Sasson, Jack M. Goodman

5. Longitudinal Study by Two-Dimensional Speckle-Tracking Echocardiography of the Left Ventricle Rotational Mechanics during Postnatal Adaptation in Healthy Newborns

   Publication date: Available online 4 December 2019

   Source: Journal of the American Society of Echocardiography

   Author(s): Johanne Auriau, Ba Luu Truong, Stéphanie Douchin, Hélène Bouvaist, Gabrielle Michalowicz, Yves Usson, Pierre-Simon Jouk

6. A Practical Guide to Assess the Reproducibility of Echocardiographic Measurements

   Publication date: December 2019

   Source: Journal of the American Society of Echocardiography, Volume 32, Issue 12

   Author(s): Karina V. Bunting, Richard P. Steeds, Luke T. Slater, Jennifer K. Rogers, Georgios V. Gkoutos, Dipak Kotecha

   Echocardiography plays an essential role in the diagnosis and assessment of cardiovascular disease. Measurements derived from echocardiography are also used to determine the severity of disease, its progression over time, and to aid in the choice of optimal therapy. It is therefore clinically important that echocardiographic measurements be reproducible, repeatable, and reliable. There are a variety of statistical tests available to assess these parameters, and in this article the authors summarize those available for use by echocardiographers to improve their clinical practice. Correlation coefficients, linear regression, Bland-Altman plots, and the coefficient of variation are explored, along with their limitations. The authors also provide an online tool for the easy calculation of these statistics in the clinical environment (www.birmingham.ac.uk/echo). Quantifying and enhancing the reproducibility of echocardiography has important potential to improve the value of echocardiography as the basis for good clinical decision-making.

7. Quantitative Assessment of Left Ventricular Dysfunction in Fetal Ebstein's Anomaly and Tricuspid Valve Dysplasia

   Publication date: December 2019

   Source: Journal of the American Society of Echocardiography, Volume 32, Issue 12

   Author(s): Luke G. Eckersley, Lisa W. Howley, Mary E. van der Velde, Nee S. Khoo, Kandice Mah, Paul Brooks, Timothy Colen, Lisa K. Hornberger

   Background

   Fetal Ebstein's anomaly and tricuspid valve dysplasia (EA/TVD) are associated with high perinatal mortality relative to pulmonary atresia with intact ventricular septum (PAIVS), despite both requiring redistribution of the cardiac output (CO) to the left ventricle (LV). LV dysfunction is suspected to contribute to adverse outcomes in EA/TVD.

   Objective

   We sought to examine global and segmental LV function in fetal EA/TVD with comparison to normal controls and PAIVS. We hypothesized that LV dysfunction in EA/TVD is associated with abnormal LV remodeling and interventricular mechanics.

   Methods

   We retrospectively identified 63 cases of fetal EA/TVD (40 with retrograde ductal flow) and 22 cases of PAIVS encountered from 2004 to 2015 and compared findings to 77 controls of comparable gestational age. We measured the combined CO and global LV function using two-dimensional, Doppler-derived, deformational (six-segmental vector velocity imaging) and dyssynchrony indices (DIs; SD of time to peak), and a novel global DI.

   Results

   EA/TVD fetuses demonstrated abnormal LV global systolic function with reduced ejection fraction, fractional area change, and CO, while in PAIVS we observed a normal ejection fraction, fractional area change, and CO. PAIVS, but not EA/TVD, demonstrated increased LV sphericity, suggestive of remodeling, and associated enhanced radial function in the third trimester. In contrast, while EA/TVD fetuses had normal LV segmental longitudinal strain, there was abnormal radial segmental deformation and LV dyssynchrony with increased SD of time to peak and DI.

   Conclusions

   Fetal EA/TVD is associated with a lack of spherical remodeling and presence of mechanical dyssynchrony, which likely contribute to reduced CO and ejection fraction. Clinical monitoring of LV function is warranted in fetal EA/TVD. Further studies incorporating quantification of LV function into prediction models for adverse outcomes are required.

8. Normal Ranges of Left Ventricular Strain by Three-Dimensional Speckle-Tracking Echocardiography in Adults: A Systematic Review and Meta-Analysis

   Publication date: December 2019

   Source: Journal of the American Society of Echocardiography, Volume 32, Issue 12

   Author(s): Vien T. Truong, Hoang T. Phan, Khanh N.P. Pham, Hoang N.H. Duong, Tam N.M. Ngo, Cassady Palmer, Tuy T.H. Nguyen, Bao H. Truong, Minh A. Vo, Justin T. Tretter, Sherif F. Nagueh, Eugene S. Chung, Wojciech Mazur

   Background

   Establishing normal values and associated variations of three-dimensional speckle-tracking echocardiography– (3DSTE-) derived left ventricular (LV) strain is necessary for accurate interpretation and comparison of measurements. We aimed to perform a meta-analysis of normal ranges of LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) measurements derived by 3DSTE and to identify confounding factors that may contribute to variance in reported measures.

   Methods

   The authors searched four databases, PubMed, Scopus, Embase, and Cochrane Library, through January 2019 using the key terms “left ventricular/left ventricle/left ventricles”, “strain/deformation/speckle tracking”, and “three dimensional/three-dimensional/three-dimension/three dimension/3D”. Studies were included if the articles reported LV strain using 3DSTE in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effects model with a 95% CI. Heterogeneity across studies was assessed using the I² test. Effects of demographic (age), clinical, and vendor variables were assessed in a metaregression. The National Institutes of Health tools were used to assess the quality of included articles. Publication bias was examined by Begg's funnel plot and Egger's regression test.

   Results

   The search yielded 895 articles. After abstract and full-text screening we included 33 data sets with 2,346 patients for meta-analysis. The reported normal mean values of GLS among the studies varied from −15.80% to −23.40% (mean, −19.05%; 95% CI, −18.18% to −19.93%; I² = 99.0%), GCS varied from −15.50% to −39.50% (mean, −22.42%; 95% CI, −20.96% to −23.89%, I² = 99.7%), GRS varied from 19.81% to 86.61% (mean, 47.48%; 95% CI, 41.50%-53.46%; I² = 99.8%), and GAS varied from –27.40% to –50.80% (mean, –35.03%; 95% CI, –33.19% to –36.87%; I² = 99.3%). Software for strain analysis was consistently associated with variations in normal strain values (GLS: P = .016; GCS: P < .001; GRS: P < .001; GAS: P < .001).

   Conclusions

   Variations in the normal ranges across studies were significantly associated with the software used for strain analysis, emphasizing that this factor must be considered in the interpretation of strain data.

9. Incremental Utility of Right Ventricular Dysfunction in Patients With Myeloproliferative Neoplasm–Associated Pulmonary Hypertension

   Publication date: December 2019

   Source: Journal of the American Society of Echocardiography, Volume 32, Issue 12

   Author(s): Jiwon Kim, Spencer Krichevsky, Lola Xie, Maria Chiara Palumbo, Sara Rodriguez-Diego, Brian Yum, Lillian Brouwer, Richard T. Silver, Andrew I. Schafer, Ellen K. Ritchie, Maria Mia Yabut, Claudia Sosner, Evelyn M. Horn, Richard B. Devereux, Joseph M. Scandura, Jonathan W. Weinsaft

   Background

   Myeloproliferative neoplasm (MPN) has been associated with pulmonary hypertension (PH) on the basis of small observational studies, but the mechanism and clinical significance of PH in MPN are not well established. The aims of this study were to expand understanding of PH in a well-characterized MPN cohort via study of PH-related symptoms, mortality risk, and cardiac remodeling sequalae of PH using quantitative echocardiographic methods.

   Methods

   The population comprised a retrospective cohort of patients with MPN who underwent transthoracic echocardiography: Doppler-derived pulmonary arterial systolic pressure applied established cutoffs for PH (≥35 mm Hg) and advanced PH (≥50 mm Hg); right ventricular (RV) performance was assessed via conventional indices (tricuspid annular plane systolic excursion [TAPSE], S′) and global longitudinal strain. Symptoms and mortality were discerned via standardized review.

   Results

   Three hundred one patients were studied; 56% had echocardiography-demonstrated PH (20% advanced) paralleling a high prevalence (67%) among patients with invasively quantified PASP. PH was associated with adverse left ventricular (LV) remodeling indices, including increased myocardial mass and diastolic dysfunction (P ≤ .001 for all): LV mass and filling pressure (P < .01) were associated with PH independent of LV ejection fraction. RV dysfunction by strain and TAPSE and S′ increased in relation to PH (P ≤ .001) and was about threefold greater among patients with advanced PH compared with those without PH. Patients with RV dysfunction were more likely to report dyspnea, as were those with advanced PH (P < .05). During median follow-up of 2.2 years, all-cause mortality was 27%. PH grade (hazard ratio, 1.9; 95% CI, 1.1–3.0; P = .012) and TAPSE- and S′-demonstrated RV dysfunction (hazard ratio, 3.3; 95% CI, 1.3–8.2; P = .01) were independently associated with mortality; substitution of global longitudinal strain for TAPSE and S′ yielded similar associations of RV dysfunction with death (hazard ratio, 3.2; 95% CI, 1.5–6.7; P = .003) independent of PH.

   Conclusions

   PH is highly prevalent in patients with MPN and is linked to LV diastolic dysfunction; echocardiography-quantified RV dysfunction augments risk for mortality independent of PH.

10. Global Left Ventricular Strain at Presentation Is Associated with Subsequent Recovery in Patients with Peripartum Cardiomyopathy

    Publication date: December 2019

    Source: Journal of the American Society of Echocardiography, Volume 32, Issue 12

    Author(s): Masataka Sugahara, Nobuyuki Kagiyama, Nina E. Hasselberg, Lori A. Blauwet, Joan Briller, Leslie Cooper, James D. Fett, Eileen Hsich, Gretchen Wells, Dennis McNamara, John Gorcsan, IPAC Investigators

    Background

    Peripartum cardiomyopathy (PPCM) is a serious complication of pregnancy associated with variable degrees of left ventricular (LV) recovery. The aim of this study was to test the hypothesis that global LV strain at presentation has prognostic value in patients with PPCM.

    Methods

    One hundred patients with PPCM aged 30 ± 6 years were enrolled in the multicenter Investigation in Pregnancy Associated Cardiomyopathy study along with 21 normal female control subjects. Speckle-tracking global longitudinal strain (GLS) and global circumferential strain (GCS) analysis was performed. The predefined primary combined outcome variable was death, transplantation, LV assist device implantation, or evidence of persistent LV dysfunction (LV ejection fraction [LVEF] < 50%) at 1 year.

    Results

    GLS measurement was feasible in 110 subjects: 89 of 90 patients with PPCM (99%) with echocardiographic data and all 21 control subjects. Of 84 patients (94%) with 1-year follow-up, 21 (25%) had unfavorable primary outcomes: four LV assist device placements, two deaths, and 15 patients with persistent LV dysfunction. GLS at presentation with a cutoff of 10.6% (absolute value) was specifically associated with the subsequent primary outcome with 75% sensitivity and 95% specificity. GCS at presentation with a cutoff of 10.1% was associated with the primary outcome with 78% sensitivity and 84% specificity. GLS and GCS remained significantly associated with outcomes after adjusting for LVEF (GLS odds ratio, 2.07; P < .001; GCS odds ratio, 1.37; P = .005). GLS was significantly additive to LVEF (C statistic = 0.76–0.91, net reclassification improvement = 1.32, P < .001).

    Conclusions

    GLS and GCS in patients with PPCM at presentation were associated with subsequent clinical outcomes, including death, LV assist device implantation, and evidence of persistent LV dysfunction. Strain measures may add prognostic information over LVEF for risk stratification.