Mitral regurgitation (MR) is the most common left-sided valvular heart disease worldwide and carries significant morbidity and mortality when untreated. The expanding use of transcatheter mitral valve interventions (TMVIs), including mitral transcatheter edge-to-edge repair (M-TEER) and transcatheter mitral valve replacement (TMVR), to anatomically complex, high-risk patient populations has substantially increased the demands on intraprocedural echocardiographic guidance. Yet current consensus documents provide modality-level guidance without explicitly formalizing the divergent imaging requirements inherent to these two mechanistically distinct interventions. This state-of-the-art review synthesizes evidence on intraprocedural echocardiographic guidance for TMVIs, integrating current data on 2D and 3D transesophageal echocardiography, real-time multiplanar reconstruction (MPR), echocardiography-fluoroscopy fusion imaging, 3D intracardiac echocardiography, and artificial intelligence (AI)-assisted decision-support tools. Two fundamentally distinct imaging paradigms are identified and formalized: a leaflet-level, temporally driven framework for M-TEER and an annular-level, spatially driven framework for TMVR. These paradigms reflect divergent anatomical targets and imaging priorities, with concrete implications for workflow design, operator-echocardiographer communication, and complication avoidance. Real-time MPR serves as the geometric backbone bridging 2D temporal precision with 3D spatial clarity. AI-assisted tools provide a computational guidance layer enhancing spatial consistency and procedural reproducibility while preserving, and not replacing, expert echocardiographic judgment. Effective intraprocedural echocardiographic guidance is objective-driven rather than modality-centric. The modalities described in this review function not as interchangeable alternatives but as complementary layers of a coherent, workflow-integrated architecture. The transition toward integrated, platform-based multimodal guidance defines the trajectory of next-generation TMVI echocardiography, requiring rigorous prospective validation, protocol standardization across device platforms, and training frameworks that reflect the multimodal nature of modern structural practice.
Global longitudinal strain (GLS) is a marker of subclinical myocardial dysfunction and predicts adverse outcomes in severe aortic stenosis. However, its ability to predict the magnitude of left ventricular (LV) reverse remodeling following surgical aortic valve replacement (SAVR) remains uncertain. In 94 patients with severe aortic stenosis and preserved ejection fraction undergoing SAVR, patients were stratified by baseline GLS (normal, < –16
Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis across all surgical risk groups. Traditionally performed under general anesthesia with transesophageal echocardiography (TEE) guidance, TAVI has evolved toward a minimalist approach using local anesthesia and conscious sedation (LACS), supported by transthoracic echocardiography (TTE) or fluoroscopy alone. Despite this shift, intraprocedural imaging remains valuable as it offers real-time imaging guidance throughout the procedures, allowing for rapid and accurate assessment of complication and procedural results. Echocardiographic modalities used during TAVI include TTE, TEE (adult-, mini-, or micro-TEE) and intracardiac echocardiography (ICE), each with its own advantages and limitations. While TTE is widely used in uncomplicated cases, its image quality may be suboptimal, leading to missing complications and underestimation of paravalvular leak (PVL). In contrast, TEE provides superior spatial resolution, enabling comprehensive real-time assessment and improved PVL detection and other complications. Moreover, 3D TEE offers accurate assessment of the aortic annulus and aids in sizing of the prosthesis when computed tomography is suboptimal or unavailable. ICE is an attractive alternative as it provides real-time high-resolution images and can be performed under LACS by the same operator, although it is costly with single use and requires additional venous access. ICE may be particularly helpful in patients with challenging TTE windows, or in those with contraindications for TEE. We propose an upfront intraprocedural TEE strategy in patients with high-risk anatomies undergoing TAVI, and those with poor TTE window or renal impairment in whom minimal contrast usage is preferred. Mini-TEE (with a smaller probe) is the preferred modality for intraprocedural guidance, which has 3D imaging with good resolution, and is well tolerated under LACS. In conclusion, imaging strategies in TAVI should be individualized. While minimalist approaches are feasible, TEE remains indispensable in complex cases to optimize outcomes and minimize complications.
Echocardiography is the primary imaging modality for evaluating cardiovascular disease, providing comprehensive assessment of cardiac structure, function, and hemodynamics. Its noninvasive nature, wide availability, and absence of radiation make it particularly suitable for repeated use, including in younger women and during pregnancy. Moreover, women-specific cardiovascular diseases are not uncommonly detected by echocardiography. However, smaller cardiac size, higher baseline ejection fraction, and technical limitations in women may affect interpretation. This review highlights the role of echocardiography across cardiovascular conditions relevant to women, including heart failure with preserved ejection fraction, coronary microvascular dysfunction, pulmonary hypertension, and valvular heart disease. It also addresses stress-induced cardiomyopathy, physiological changes during pregnancy, and peripartum cardiomyopathy.
Artificial intelligence (AI) is rapidly advancing from automated measurement to full-report generation, yet existing frameworks do not provide a unified scoring approach for both human- and AI-authored reports. We developed EchoPeer, a three-step evaluation framework for echocardiography reports, scored against a reference standard. Step 0 (safety score,
This prospective randomized study protocol is designed to determine whether low-concentration iodine contrast media can maintain coronary enhancement on coronary computed tomography angiography (CCTA) compared with high-concentration iodine contrast media under standardized acquisition conditions. Dynamic stress computed tomography perfusion (CTP)-derived myocardial blood flow (MBF) will be assessed as a key secondary quantitative endpoint. Exploratory diagnostic performance analyses using invasive coronary angiography (ICA) and fractional flow reserve (FFR) will be performed only in clinically indicated invasive testing subgroups. The trial plans to enroll 258 adults (age ≥ 40 years) with known or suspected coronary artery disease referred for clinically indicated cardiac computed tomography, including CCTA with planned dynamic stress CTP. Participants will be randomized 1:1 to receive low-concentration iodine contrast media (270 mg I/mL) or high-concentration iodine contrast media (350 mg I/mL). The primary endpoint is quantitative coronary enhancement on CCTA. Dynamic stress CTP-derived MBF will be evaluated as a key secondary endpoint focused on quantitative comparability. ICA/FFR-based diagnostic performance analyses will be considered prespecified exploratory analyses in participants who undergo invasive testing as part of routine clinical care. The primary endpoint will be analyzed using linear mixed-effects models with a prespecified noninferiority margin, and MBF will be analyzed using mixed-effects models without claiming formal equivalence or noninferiority. This study protocol is expected to clarify whether low-concentration iodine contrast media can maintain CCTA coronary enhancement and support quantitative dynamic stress CTP assessment while reducing iodine exposure. Because ICA and FFR are clinically driven rather than protocol mandated, diagnostic performance analyses will be interpreted cautiously and regarded as exploratory. CRIS identifier: KCT0011418. Registered on January 7, 2026.
The DynamX bioadaptor is a novel coronary implant with three helical strands that unlock and separate to provide dynamic vessel support restoring natural vessel function. Evidence in complex bifurcation lesions requiring planned two-stent strategies is limited. This analysis evaluated the feasibility and short-term outcomes of culotte bioadaptor implantation using intravascular ultrasound (IVUS). Thirteen consecutive patients underwent bifurcation percutaneous coronary intervention using culotte technique with DynamX bioadaptor between February and October 2025. All procedures followed a standardized culotte protocol with lesion preparation, proximal optimization technique, rewiring, and final kissing balloon inflation, with IVUS used to assess bioadaptor expansion, apposition, and structural integrity. Technical and procedural success was achieved in all patients (100
Echocardiographic guidance plays a pivotal role in pre-procedural screening and intraprocedural guidance for transcatheter tricuspid valve interventions (TTVI). Pre-procedurally, comprehensive transesophageal echocardiography (TEE) is essential to understand the tricuspid regurgitation (TR) mechanism, quantify TR severity, tricuspid leaflet morphology, right ventricular function/size, and help determine transcatheter tricuspid edge-to-edge repair (T-TEER) and transcatheter tricuspid valve replacement (TTVR) selection based on underlying tricuspid valve anatomy. Interprocedurally, the use of real-time three-dimensional transesophageal echocardiography (3D-TEE) together with fluoroscopy allows precise guidance of device steering, leaflet insertion, and deployment while minimizing complications, especially in technically challenging tricuspid valve anatomy. Post-device deployment echocardiography assists in the assessment of residual TR, paravalvular leak, transvalvular gradient, right ventricular function changes, and the occurrence of pericardial effusion. As device technologies and indications for TTVI continue to expand, high-quality echocardiographic protocols and expertise are central to optimizing patient selection, procedural safety, and long-term outcomes in transcatheter treatment of tricuspid valve regurgitation.
Transthyretin amyloid cardiomyopathy (ATTR-CM) has undergone a shift towards noninvasive diagnostics using bone tracer scintigraphy with Perugini grading. While both grades 2 and 3 are considered diagnostic, potential phenotypic differences between these groups remain uncertain. We aimed to evaluate the diagnostic yield of technetium-99 m pyrophosphate (99mTc-PYP) scintigraphy and to compare clinical and multimodality imaging characteristics across scintigraphic grades in a single-center cohort. We retrospectively reviewed all patients who underwent 99mTc-PYP scintigraphy for suspected cardiac amyloidosis between 2018 and 2025. Patients with confirmed ATTR-CM were stratified by Perugini grade (grade 2 vs. grade 3). Clinical features, biomarkers, electrocardiography, echocardiography, and cardiac magnetic resonance (CMR) parameters were compared. Correlations between scintigraphic grade, imaging markers, and biomarkers were assessed. Among 302 scans, 103 (34.1
Khidr and colleagues recently reported an intermodality comparison of left ventricular longitudinal strain by feature-tracking cardiac magnetic resonance (FT-CMR) and 2D speckle-tracking echocardiography (2D-STE) in 55 stable patients with chronic ischemic heart disease and reduced ejection fraction. Their analysis showed a strong global longitudinal strain (GLS) correlation (r = 0.793, P < 0.001) and explicitly cautioned against treating the two modalities as interchangeable for individual or longitudinal assessment. We support these conclusions and write to extend two methodological points. First, the 17 segment-level paired comparisons in Table 4 are reported without explicit multiplicity adjustment. On recomputation against a Bonferroni threshold of α/17≈0.00294, 11 of 17 segmental differences remain statistically significant, indicating that the original segmental signal is more statistically robust than an unadjusted reader might assume; we therefore recommend explicit reporting of adjusted P-values together with a unified mixed-effects formulation that accommodates within-patient segment-to-segment correlation. Second, the GLS limits of agreement span 8.3 percentage points (− 3.2
Pneumonia remains a major cause of morbidity and mortality worldwide, and right ventricular dysfunction may contribute to adverse clinical outcomes. Right ventricular global longitudinal strain (RVGLS) is an emerging echocardiographic marker for assessing right ventricular function, but its prognostic and clinical utility in pneumonia has not been fully clarified. Eighty patients hospitalized with pneumonia underwent echocardiographic assessment, including RVGLS measurement via 2D speckle tracking echocardiography. Patients were categorized into two groups: reduced RVGLS (absolute value < 20
Transthoracic echocardiography (TTE) requires time-intensive integration of quantitative measurements and qualitative visual assessment. Fully automated artificial intelligence (AI)-based analysis may reduce total analysis time while preserving accuracy, but systematic real-world validation remains limited. This prospective, single-center pilot study enrolled 40 TTE examinations. Identical deidentified DICOM datasets were independently provided to a trained cardiac sonographer and a fully automated AI system comprising quantitative and qualitative visual interpretation modules. All outputs were compared with a cardiologist-adjudicated reference standard. Primary endpoints were total analysis time and noninferiority of AI-derived left ventricular ejection fraction (LVEF) versus the reference standard, with a prespecified margin of 3 percentage points (one-sided α = 0.025). Median analysis time was 94 s (interquartile range [IQR], 82–106 s) for the AI workflow versus 490 s (IQR, 438–626 s) for the human workflow (P < 0.001). AI-derived LVEF met the noninferiority criterion (mean difference, 0.00 percentage points; upper one-sided 95
Anthracycline-based chemotherapy is highly effective in breast cancer treatment but is limited by dose-dependent cardiotoxicity. Early identification of subclinical myocardial injury is crucial to prevent progression to irreversible dysfunction. To evaluate whether a multimodal surveillance strategy integrating left ventricular global longitudinal strain (LVGLS), left atrial reservoir strain (LASr), and high-sensitivity troponin I (hs-TnI) can predict early anthracycline-induced cardiotoxicity. This retrospective cohort study included 50 female breast cancer patients (mean age 49.3 ± 8.5 years) treated between January 2022 and December 2024. Echocardiography and biomarkers were assessed at baseline and 1 month after chemotherapy. Cardiotoxicity was defined as a > 10
Global longitudinal strain (GLS) is a valuable tool for assessing left ventricular (LV) systolic function, detecting subclinical dysfunction earlier than classic ejection fraction. Two-dimensional speckle-tracking echocardiography (2D-STE) is widely used due to its accessibility and high temporal resolution, whereas feature-tracking cardiac magnetic resonance (FT-CMR) offers superior spatial resolution and reproducibility. In this study, we assess the relationships between longitudinal strain measurements obtained by 2D-STE and FT-CMR in patients with chronic ischemic heart disease (IHD). Fifty-five patients with IHD and left ventricular ejection fraction (LVEF) ≤ 49
Small studies suggest that variations in plasma potassium (p-K) levels may affect cardiac contractile function. A substudy to the recently published POTCAST trial demonstrated short-term improvements in myocardial function in patients randomized to potassium-increasing treatment. However, the long-term effects of increasing p-K on cardiac function remain unclear. This study aimed to investigate whether treatment that increases p-K improves diastolic and systolic myocardial function as assessed by echocardiography during long-term follow-up in a Danish implantable cardioverter-defibrillator (ICD) cohort. The POTCAST trial randomized patients with an ICD (1:1) to either usual therapy (control group) or treatment with oral potassium supplements and/or mineralocorticoid receptor antagonists (high-normal potassium group). In this substudy, consecutive patients from both arms of the POTCAST trial were included. Echocardiography was performed at baseline and repeated after > 6 months for the current study to compare changes in left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), global constructive work (GCW), and diastolic parameters (E, e’, and E/e’) between the high-normal potassium and control groups. A total of 289 patients (mean age, 58 ± 13.4 years; 77.5
Anthracycline-based chemotherapy agents are widely used and are highly effective, particularly for breast cancer treatment. Although the cardiotoxic effects of anthracyclines on left ventricular (LV) function are well established, their impact on right ventricular (RV) function has not been sufficiently investigated. This study aimed to evaluate the effects of anthracycline therapy on RV function and to compare them with LV function to determine the potential cardiotoxic effects on both ventricles. This single-center retrospective cohort study included 38 female patients with breast cancer who were treated with anthracyclines between January 2021 and June 2023. Echocardiographic parameters and cardiac biomarkers were evaluated at baseline and at 6-month follow-up visit. LV ejection fraction (LVEF) was calculated using the Teichholz method due to the retrospective design. RV function was assessed by tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (sPAP), and the TAPSE/sPAP ratio. Cancer therapy–related cardiac dysfunction (CTRCD) was defined according to current European Society of Cardiology criteria. Serum troponin I and pro–brain natriuretic peptide levels were recorded. Paired comparisons were performed using the paired-samples t-test. Following anthracycline therapy, LV end-systolic diameter increased (2.76 ± 0.24 cm vs. 3.03 ± 0.29 cm, P < 0.001), and LVEF decreased (67.3
We aim to analyze the additive value of repeated transthoracic echocardiography (TTE) within a 1-week interval after a baseline TTE to diagnose infective endocarditis (IE) in patients admitted with Staphylococcus aureus bacteremia (SAB). We prospectively enrolled consecutive patients with SAB who were referred for TTE and transesophageal echocardiography (TEE) to exclude IE between January 2017 to December 2019. All patients underwent a second TTE within 5 to 7 days. We excluded patients with poor echo windows, previous IE, valve repair/replacement, and those with cardiac devices or a dialysis catheter in place. A total of 105 patients were enrolled, of which 40 (38.1
Transthoracic echocardiography derived left ventricular ejection fraction (LVEF) is a cornerstone in heart failure risk prevention. However, the lower limits of normal LVEF remains imprecisely defined. We aimed to define normal LVEF ranges by sex, age group, and self-reported race/ethnicity using data from population-based echocardiographic studies. We systematically searched MEDLINE for studies published between January 1, 2000, and January 3, 2025, that reported the mean and standard deviation of LVEF measured by 2D or 3D echocardiography in healthy, community-based adult populations. In 10 studies (n = 10,427; female sex, 48
