Patient selection for transcatheter mitral valve edge-to-edge repair (MTEER) remains challenging, particularly in individuals with complex mitral valve anatomy. Conventional risk scores incorporate limited clinical variables and do not adequately account for detailed echocardiographic features, resulting in suboptimal prediction of procedural success. To develop and evaluate machine learning (ML) and deep learning (DL) models integrating clinical and echocardiographic data to predict procedural success following MTEER. Consecutive patients undergoing MTEER at a single tertiary center between 2014 and 2022 were retrospectively analyzed. Procedural success was defined as residual mitral regurgitation ≤ mild and mean mitral valve gradient < 5 mmHg at the end of the procedure. Pre-procedural transesophageal echocardiographic (TEE) videoclips were used to generate image datasets for ML and DL model training. Machine Learning algorithms (Decision Tree, Random Forrest, Gradient Boosting, k-Nearest Neighbors, Support Vector Machines) were used to predict the primary outcome from patient demographics and baseline TEE measurements. Inception, Xception, and MobileNet architectures were evaluated using 10-fold cross-validation with strict patient-level data separation. Model performance was assessed using accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). Among 467 included patients, procedural success was achieved in 90.7
Dynamic left ventricular outflow tract (LVOT) obstruction is a common and consequential feature of hypertrophic cardiomyopathy (HCM), present in a majority of patients at rest or with provocation, and it directly influences symptom burden and eligibility for therapy. When obstruction is absent at rest it can be provoked by physiologic stimuli, including the ingestion of a meal, a phenomenon patients have reported for decades. Whether postprandial assessment improves detection of obstructive physiology over conventional provocative testing has not been systematically examined. We searched PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science from inception through June 2025. Study quality was assessed with the Newcastle-Ottawa Scale. Because of substantial heterogeneity in study protocols and outcome definitions, we performed a narrative synthesis rather than a meta-analysis. Seven studies met inclusion criteria, published between 1991 and 2024 across three countries. Across these studies, postprandial assessment consistently provoked higher LVOT gradients than fasting measurement and identified obstructive physiology in patients with no obstruction on conventional testing. In the most rigorous comparative study, postprandial echocardiography identified gradients ≥ 30 mmHg in 74
Shock is the clinical state whereby the patient’s circulation fails to meet the body’s metabolic demands. Both acute illnesses that lead to shock and therapies employed to support the shocked patient (including intravenous fluids, vasoactive infusions and ventilatory support) may result in changes to the normal function of the heart. The conventional approach to interpretation of echocardiography in the steady physiological state needs modification when this test is applied to the shocked patient. In this paper we explain when and why modifications are required, and provide echocardiographers already established in outpatient practice with a practical approach to performing and reporting echocardiograms in shocked patients.
We evaluated the trajectories of echocardiographic myocardial work (MW) indices and their associations with left ventricle (LV) functional recovery, myocardial viability, and perfusion in patients with reperfused acute myocardial infarction (AMI). Thirty-one patients with a first ST-elevation AMI treated with percutaneous coronary intervention were prospectively enrolled. Transthoracic echocardiography and [15O]-water positron emission tomography (PET) were performed at a median of 7.7 ± 3.8 days post- intervention (baseline). Global and segmental absolute myocardial blood flow (MBF) were assessed using PET, and myocardial segments were graded as viable or non-viable based on perfusable tissue fraction (PTF). Echocardiographic parameters, including LV ejection fraction (LVEF), global longitudinal strain (GLS), myocardial work index (MWI), constructive work (MCW), wasted work (MWW), and work efficiency (MWE), were measured at baseline and at the 6-month follow-up. The myocardial area at risk (AAR) and the remote myocardium were defined based on the culprit coronary artery segment. LVEF and GLS remained unchanged between baseline and follow-up. However, global MWI, MCW, and MWE significantly increased, while MWW decreased at the 6 months (all p < 0.05). An increase in MWI, but not MWE, was associated with improvement of LVEF. Neither global MWI nor MWE correlated with global MBF, but were inversely associated with peak levels of troponin T and NT-proBNP. In the AAR, regional MWI and MWE were significantly correlated with regional MBF (r = 0.53, p = 0.003, and r = 0.59, p < 0.001, respectively) and PTF (r = 0.41, p = 0.03, and r = 0.65, p < 0.001, respectively). At baseline, segmental MWI and MWE were higher in viable compared to non-viable segments. At 6 months, MWI and MWE increased in viable, but not in non-viable segments. Echocardiographic myocardial work indices reflect the severity of myocardial injury early after AMI and may serve as non-invasive markers of functional recovery and myocardial viability.
Duchenne muscular dystrophy (DMD) is a genetically determined, neuromuscular disorder occurring predominantly in males with a prevalence of 1:3,500 to 1:5,000 live male births. It is a life limiting condition with average life expectancy of only 28.1 years in the United Kingdom. A dilated cardiomyopathy occurs in all patients with DMD, and cardio-respiratory causes now account for about 80
Echocardiography is a foundational imaging modality for assessing cardiac structure and function, with a long history of technological advancement. As artificial intelligence (AI) becomes increasingly embedded across healthcare, its potential to enhance the echocardiography workflow, from image acquisition and analysis to reporting and risk stratification, has expanded rapidly. Research activity in this field has grown substantially, yet clinical adoption remains variable and often limited by practical, technical, and governance challenges. In response, the British Society of Echocardiography has developed this position statement to provide a structured, consensus‑driven evaluation of the opportunities, limitations, and requirements for the safe, equitable, and effective integration of AI into echocardiography services. Although centred on the UK context, the principles outlined may be relevant to other healthcare systems with similar models of echocardiography delivery.
BACKGROUND:Reported adverse events (AEs) to the Food and Drug Administration Adverse Event Reporting System (FAERS) have suggested an increased rate of serious AEs (SAEs) during the COVID-19 pandemic, but the extent to which this may be related to overall changes in reporting during this time period is uncertain. Accordingly, we aimed to evaluate trends in SAE reporting across commercially available ultrasound enhancing agent (UEA) brands as a function of overall trends in AE reporting. METHODS:We retrospectively analyzed the FAERS public database, 2014-2024, to evaluate risks of UEAs overall and by brand, compared to similar contrast media. RESULTS:Between 2014 and 2024, 21,960,760 AEs were reported to FAERS, of which 11,450,891 (52.1%) were categorized as SAEs. Overall SAE reports to FAERS increased from 678,953 in 2014 to 1,368,393 in 2021 before subsequently declining to 1,065,845 in 2024 (-7.9% change from 2021 to 2024). During the same period, overall death reports to FAERS increased from 124,055 in 2014 to 195,207 in 2018 before declining to 147,046 in 2024. During this period of decline, there was a 23.9% relative increase in SAEs to UEAs which peaked in 2023 at 350 before declining to 326 in 2024. Deaths attributed to SAEs increased from 1 in 2014 to 19 in 2023 before declining to 9 in 2024. Overall, these data suggest that 11.2% of the observed increase in SAEs to UEAs can be attributed to reporting changes. Despite changes in relative risks for SAEs, absolute SAE rates remained small and lower than other types of contrast media. CONCLUSIONS:In this analysis of the FAERS dataset, 2014-2024, 11.2% of SAEs to UEAs were attributable to temporal changes in AE reporting. Absolute risks are small and declining, suggesting broad safety of UEAs as a class. Collectively, these results support continued use of UEAs, but motivate improved safety screening and preparedness to mitigate small but existing risks.
Arterial hypertension remains the leading modifiable cause of cardiovascular morbidity and mortality resulting in characteristic changes in cardiac structure and function. Contemporary hypertension clinical guidelines increasingly emphasise prevention and early detection of hypertension-mediated organ damage, yet they differ in how blood pressure is categorised and when further investigation is recommended. Within this prevention-focused landscape and alongside a broader cardio-renal-metabolic framework, this review provides a practical overview on the role of echocardiography in arterial hypertension by integrating contemporary hypertension guidelines with imaging consensus documents. We outline when echocardiography is most likely to add value in hypertension and review echocardiographic assessment of left ventricular structure and geometry, systolic and diastolic function and filling pressures, atrial remodelling, right ventricular assessment, valvular heart disease and the aorta. Practical indications for scanning and transoesophageal echocardiography considerations are discussed. Finally, we highlight future directions including prevention-focused pathways, scalable echocardiography strategies, routine inclusion of contemporaneous blood pressure in reports, artificial intelligence-enabled quantification and selective multimodality imaging within specialist hypertension services.
Abstract Background Participation in regular endurance exercise may be associated with physiological left ventricular (LV) dilatation and concomitant low resting LV ejection fraction (LVEF), a phenotype indistinguishable from early dilated cardiomyopathy (DCM) on resting imaging alone and termed the “grey zone”. Stress echocardiography has emerged as a potential arbiter and has been proposed to resolve this dilemma. Objectives We evaluated the diagnostic accuracy of stress echocardiography in distinguishing physiological from pathological LV dilatation and assessed whether incorporating submaximal-to-peak contractile reserve improved discriminatory value in athletes in the grey zone. Methods Of the 182 athletic individuals, 62 control athletes with an enlarged LV and normal LVEF, 58 athletic DCM individuals, and 62 grey zone athletes underwent stress echocardiography using a semi-supine bicycle. In addition to the ability to augment LVEF ≥ 10% from rest to maximal exercise, we evaluated the ability to augment LVEF from submaximal exercise (80% of maximal heart rate) to peak exercise. Results Resting LV dimensions did not differ significantly amongst the groups. Control athletes had higher resting LVEF than grey zone athletes and DCM individuals (62.1% vs 52.1% and 53.1%; p=<0.001). Control and grey zone athletes showed greater ΔLVEF from rest to peak exercise than DCM individuals (21% and 19.2% vs 4.9%; p < 0.001). Most control (98.3%) and grey-zone athletes (90.3%) achieved a ΔLVEF ≥ 10% from rest to peak exercise compared with 20.6% of athletic DCM individuals. Control and grey zone athletes also revealed a mean increase in LVEF from submaximal to peak exercise of 7.5% and 3.8%, respectively, whereas DCM individuals showed a mean LVEF decline of −4.3% (p < 0.001). Although 20.6% of DCM individuals demonstrated a ΔLVEF ≥ 10% from rest to peak, only a single DCM individual augmented LVEF from submaximal to peak exercise. Failure to increase LVEF ≥ 10% from rest to peak exercise identified DCM with 79.4% sensitivity and 98.3% specificity. Combining this inability with a failure to augment LVEF from submaximal to peak exercise improved the sensitivity to 98.2% and specificity to 98.4%. Conclusion Reliance on rest-to-peak augmentation of ≥10% alone risks misclassification. Introducing submaximal-to-peak augmentation enhances diagnostic precision by identifying virtually all individuals with DCM while preserving specificity.
Abstract Background To improve standardization, the 2025 American Association of Echocardiography (ASE) guidelines revised the definitions of right ventricular (RV) basal and mid diameters, revising the 2010 ASE and European Society of Cardiology (ESC) definitions. Objectives (1) To quantify differences in right ventricular (RV) diameter measurements between the 2010 and 2025 ASE guidelines, (2) to determine its impact on the diagnosis of RV enlargement (RVE), and (3) to compare these findings with a novel automated non-linear centerline-based approach. Methods We analyzed 208 healthy volunteers and 221 patients with pulmonary arterial hypertension (PAH). Using custom cardiac contour analysis (C2A) software, RV diameters were measured across three definitions. The 2010 ASE/ESC defines diameters as the maximal dimension in the basal and mid segments. In contrast, the 2025 ASE defines the basal diameter just below the tricuspid valve and the mid diameter at ~ 50% of RV inflow, both parallel to the annulus. The C2A method uses a non-linear RV centerline as a reference to standardize measurement locations: the mid-point is taken at 50% along the centerline, and the basal diameter is defined as the maximum perpendicular distance within the proximal third of the RV. We quantified nominal and relative definition differences and compared sex-specific RVE prevalence in healthy controls. Diagnostic performance (ROC) and outcome prediction (Cox models) are presented. Results The median age was 63 years in healthy volunteers (52% male) and 48 years in patients with PAH (22% male), with a median pulmonary vascular resistance index (PVRI) of 22 Wood units·m². Compared to ASE/ESC 2010 definitions, ASE 2025 diameters were 15% (basal) and 20% (mid) lower. Using the 2025 definition in healthy controls, basal RVE was observed in 1% of females and 22% of males, while mid-RVE was present in 6% of females and 35.8% of males. The 2010 definition showed slightly better discrimination for PAH (AUC 0.937 vs. 0.898, p < 0.001). However, the prediction of outcomes was similar between the two definitions, with C-statistics of 0.59 (0.53–0.65) and 0.59 (0.53–0.66), respectively. Conclusion Differences in guideline definitions of RV diameters are important to consider when implementing them in clinical practice.
BACKGROUND: The assessment of the right heart (RH) plays a central role in the diagnosis and management of cardiovascular and pulmonary diseases. Although current guidelines have improved standardization, there is anecdotal evidence suggesting that there is significant variability in clinical practice regarding acquisition and reporting persist. OBJECTIVES: This international survey evaluated the extent of variability in echocardiographic assessment of the RH. A simple method for the standardization of RH measurements is proposed. METHODS: The international anonymous survey consisted of 68 questions with a primary focus on routine methods and measurements of RH echocardiography by transthoracic (TTE) and transesophageal (TEE) modalities. The questions were developed using a standardization framework, focused on six key areas: views and settings, phase, orientation, interface, timing and selection, as well as scaling and indexing (V-POINTS). RESULTS: The survey was available from November 2024 to February 2025. A total of 588 international respondents from various disciplines and professions responded. The majority of respondents had certification in echocardiography (74%), 34% reported 10 to 20 years of experience, 22% reported more than 20 years of experience. The 4-chamber (80%) and right ventricular (RV) focused (67%) views were most commonly used in TTE. The functional parameters included tricuspid annular plane systolic excursion (TAPSE) (80%), visual assessment (66%), RV S’ (50%), and fractional area change (FAC) (42%). RV strain and 3D metrics were less frequently used. Using TEE the mid-esophageal 4-chamber view was most commonly used (80%), RV function was mostly assessed visually, and quantification playing a secondary role (TAPSE 44% and RVFAC 34%). There was considerable variability in the definition of cardiac phases across both modalities. RV dimensions and areas were measured at the compacted region by 58% of the respondents. Scaling and indexing were not routinely used in practice. CONCLUSIONS: The survey identified significant variability in the practice of RH echocardiography. We propose a simple system (V-POINTS) which may improve standardization of image acquisition and corresponding measurements.
BACKGROUND:Right ventricular systolic pressure (RVSP) is an echocardiographic metric to monitor pulmonary hypertension (PH). However, there is no recommendation on what constitutes a meaningful change. In this study, we aimed to gain insight into how physicians at our institution report significant changes in RVSP. We then aimed to quantify the analytic variability of reported RVSP using duplicate analysis. METHODS:We utilized the Stanford CardioShare Registry to identify 5,934 patients with 32,656 echocardiogram pairs with reported RVSP. Natural Language Processing was employed to categorize pairs into decrease, increase, no change, and no direct mention. Classification and Regression Tree (CART) analysis was applied to these groups to identify reporting thresholds among physicians. To assess the performance of the CART model, accuracy, precision, recall, and F1-score were reported using a stratified cross-validation method. In a separate cohort comprising 210 healthy volunteers and 208 patients with PH, two blinded core laboratory cardiologists measured the peak tricuspid regurgitation velocity. We employed a duplicate analysis method to model bias and a robust precision method for reporting RVSP and assessing analytical variability. RESULTS:Of the total pairs of echocardiographic studies, RVSP was reported as stable in 48.9%, increased in 12.5%, decreased in 9.9% while 28.7% did not have a direct reference to RVSP change. CART analysis revealed that physicians most commonly determine change based on an absolute threshold of 8 mmHg and whether the change occurred within or outside the reference range. On cross-validation, the accuracy and F1-score were 83% and 79% for the increase and 81% and 74% for the decrease algorithms. In the duplicate analysis cohort, the analytic precision was 8-10% with worst relative precision at lower values of RVSP. This translates into a 15% reference change value, assuming a 4-5% biological variation. CONCLUSION:The study provides insights on real world practice of physician reporting in RVSP and provides directions for future recommendations regarding report changes.
Abstract Background Current guidelines define pulmonary hypertension (PH) as a mean pulmonary artery pressure (mPAP) >20mmHg at right heart catheterisation (RHC). International transthoracic echocardiography (TTE) PH guidelines recommend a multi-parameter assessment to estimate PH probability. Effectiveness of the inclusion of right ventricular free wall strain (RVFWS) has not been established using real world data. Study aims To determine the accuracy of current European and American TTE PH guidance in detecting PH in patients attending a UK PH centre. The impact of addition of RVFWS to the efficacy of the European and American guidance was also evaluated. Methods TTE with subsequent RHC (within 1.4 months) were undertaken in patients with suspicion of PH, referred for first time investigations. Echocardiographic variables were assessed in accordance with current European and American TTE guidance. Results Of 549 patients assessed, 431 (79%) had RHC confirmed PH (average mPAP = 41mmHg). Sensitivity / specificity for detecting PH was calculated for the European Society of Cardiology (ESC) TTE PH recommendations (83% / 65% respectively); ESC + RVFWS (92% / 62% respectively); American Society of Echocardiography (ASE) TTE PH recommendations (89% / 49% respectively); ASE + RVFWS (96% / 36% respectively); TTE PASP > 35mmHg alone (75% / 73% respectively); TTE TRV > 2.8 m/s alone (77% / 78% respectively). Of those with RHC PH 3 (1%) subjects with a TRV > 2.8 m/s and 7 (3%) with a PASP > 35mmHg had no supporting signs of PH. Using TTE PASP > 35mmHg or TRV >2.8m/s with at least 2 abnormal TTE parameters (including RVFWS) gave similar sensitivity / specificity (74% / 79% vs 73% / 87% respectively). In those with RHC PH and TTE PASP >35mmHg or TRV >2.8m/s the significant majority had at least 2 TTE PH markers (99% & 97%). Whilst TTE PASP and RHC PASP correlation was good (r = 0.745), accuracy was poor with limits of agreements as high as 44mmHg (range = -29 to 44mmHg). In those with no measurable tricuspid regurgitation, 64% (n = 49) had RHC PH (11% of whole cohort); in those where TTE PASP <35mmHg 23% (n = 70) had RHC PH. In those felt to have an ESC PH low TTE probability 44% (n = 60) had RHC PH (14% of whole cohort). Incorporating RVFWS improved detection in those with a ESC low TTE PH probability, reducing false negatives by 43%. Conclusion Current TTE PH algorithms lack sensitivity to detect patients with milder haemodynamic forms of PH. This can be improved with the addition of RVFWS.
Abstract Background Systemic sclerosis (SSc) is a multisystem autoimmune disease frequently complicated by pre- and post-capillary pulmonary hypertension (PH). Within SSc, progressive diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF) are key contributors, often presenting as isolated postcapillary PH (Ipc-PH) or combined pre- and postcapillary PH (Cpc-PH). The ability to differentiate these hemodynamic phenotypes is critical for risk stratification, yet echocardiographic markers specific to each subtype in SSc-HFpEF are poorly defined. Methods We investigated 147 adults with SSc-HFpEF with echocardiograms and right heart catheterization (RHC) assessments performed within one year. Patients were classified as Ipc-PH (n = 46) or Cpc-PH (n = 101) based on guideline-defined hemodynamic criteria. Echocardiographic parameters, including conventional measures, strain indices, and coupling metrics were analyzed. A random forest (RF) classifier was used to identify top echocardiographic predictors of Cpc-PH, and further assessed using multivariable logistic regression. Separate RF models and Cox regression analyses were used to determine echocardiographic predictors of mortality within each group. Survival was assessed using Kaplan-Meier analysis. Results Patients with Cpc-PH exhibited significantly greater right heart remodeling, higher pulmonary pressures, and impaired right ventricle (RV)-pulmonary artery (PA) coupling. The top echocardiographic predictors of Cpc-PH included reduced RV free wall strain (RVFWS), decreased RVFWS/PA systolic pressure (PASP) and fractional area change (FAC)/PASP ratios, elevated PASP, lower septal e′ velocity, and higher systolic LV eccentricity index (LV EI). In adjusted Cox models, elevated LVEI (HR 1.39), increased RV internal diastolic diameter (HR 2.15), and reduced left and right atrial strain (HR 0.91 and 0.94, respectively) were independently associated with mortality in Cpc-PH. In Ipc-PH, mortality was linked to reduced FAC/PASP, lower left ventricular global longitudinal strain (LVGLS), increased LV mass index, elevated PASP, and lower RVFWS. Conclusion In the present study, we demonstrate key echocardiographic differences between Ipc-PH and Cpc-PH within the SSc-HFpEF population, emphasizing the central role of right heart remodeling, RV-PA coupling, atrial and septal mechanics in phenotypic differentiation and prognostication. Strain-based parameters and RV-PA coupling indices offer incremental value for risk stratification and may guide more tailored therapeutic strategies in this heterogeneous population.
Abstract Background The 2022 ESC/ERS guidelines redefined pulmonary hypertension (PH) as a mean pulmonary artery pressure (mPAP) >20 mmHg on right heart catheterisation (RHC). Echocardiography, using metrics such as tricuspid regurgitation velocity (TRV), tricuspid annular plane systolic excursion (TAPSE), and TAPSE/systolic pulmonary artery pressure (TAPSE/SPAP), guides referral for RHC. However, the few studies evaluating echocardiographic performance using the ESC/ERS 2022 thresholds have combined the newly included population as a relatively modest subgroup within their overall analysis. Results We present a sample of 1,991 individuals from the EVIDENCE-PAH UK database. Our data demonstrate higher TRV and sPAP values and lower TAPSE/SPAP values with higher haemodynamic category. ROC analysis demonstrates that TRV, SPAP and TAPSE/SPAP perform well as predictors of mPAP > 20 mmHg and ≥25 mmHg (AUCs 0.785–0.830), but less well at predictive mPAP 21–24 mmHg (AUCs 0.656–0.686). In all PH patients and the mild PH (21–24 mmHg) subgroup, TAPSE/SPAP < 0.31 mm/mmHg predicted reduced survival (HR 2.01–3.14, p < 0.001). Similarly, in haemodynamically mild PH, TRV > 3.4 m/s was associated with worse survival compared to TRV < 2.5 m/s or 2.5–2.8 m/s (p < 0.001). Conclusions While established echocardiographic metrics (TRV, TAPSE/SPAP) are strong predictors of significant PH (mPAP ≥25 mmHg), they are less accurate for mild PH (mPAP 21–24 mmHg). Importantly, mild PH itself is associated with increased mortality, and within this group, TRV >3.4 m/s and TAPSE/SPAP <0.31 mm/mmHg identify patients at highest risk, supporting their prognostic utility even in early haemodynamic disease.
Contrast echocardiography encompasses two forms of ultrasound contrast agents. This article focuses on agitated saline (AS-C) contrast, commonly called ‘bubble’ contrast. Its main application is in identifying the presence of a right to left shunt in a number of clinical syndromes, often associated with a patent foramen ovale (PFO). Dependant on the clinical presentation, the presence of a PFO with a likelihood of a causal role may be considered for percutaneous PFO closure. This guideline outlines a structured approach to performing an AS-C transthoracic echocardiogram, including the indications, protocols, and potential pitfalls for performing AS-C transthoracic echocardiography (TTE). It also addresses when to proceed to more advanced imaging modalities and highlights clinical decision-making frameworks such as the RoPE score.
Abstract Background Transthoracic contrast echocardiography (cTTE) is a first-line method for patent foramen ovale (PFO) assessment, but its sensitivity is reported as low and inconsistent. We aimed to investigate the sensitivity of high-density cTTE for PFO detection, and the relationship between left-heart contrast opacification grade, invasively measured shunt severity and atrial septum/PFO morphology. Methods Fifty-five consecutive patients with proven PFO on contrast transoesophageal echocardiography (cTOE) underwent cTTE with high density contrast (colloid, mannitol) and invasive quantification of right-to-left shunt severity using the thermodilution method. Echocardiographic shunt severity was classified according to the degree of left atrial (cTOE) or left atrial/ventricular (cTTE) opacification as grade 0 (no bubbles), grade 1(mild), grade 2 (moderate) grade 3 (significant opacification). Results For PFO detection, the sensitivity of rest + Valsalva cTOE was 100%. Compared with this reference, sensitivity of rest + Valsalva cTTE was 98.2%, Valsalva cTTE 97.7%, rest cTTE, 83.9% and rest cTOE, 77.3%. No significant association was observed between left-heart opacification grade on rest or Valsalva cTTE/cTOE and invasively measured right-to-left shunt severity categorized as < 10%, 10–19%, or ≥ 20% (p = 0.10–0.26). A moderate association only was identified between rest + Valsalva cTOE left atrium opacification grade and < 10% and ≥ 10% right-to-left shunt severity (p = 0.024, Cramér’s coefficient = 0.368). No significant relationship was found between left-heart opacification grade and the presence of atrial septal aneurysm, Eustachian valve/Chiari’s network, or PFO channel width and length (p = 0.45–0.77). Compared with rest cTOE, rest cTTE demonstrated equal contrast opacification grade in 56% and higher in 40%. Valsalva cTTE showed equal contrast opacification grade in 29% and higher in 46% of studies vs. Valsalva cTOE. Conclusions In studies using high-density contrast, cTOE and cTTE with Valsalva, but not rest studies, are highly sensitive for PFO assessment. There is no clinically relevant relationship between the left-heart bubble opacification grade and invasively measured right-to-left shunt severity or atrial septum morphology. The left-heart contrast opacification grade is equal to or higher in cTTE than in cTOE, especially in rest studies.
Abstract Background In patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), myocardial dysfunction may extend beyond the left ventricle and remain underrecognized by conventional severity classification paradigms. Strain echocardiography allows early detection of subclinical dysfunction across cardiac chambers, potentially enhancing prognostic stratification. Methods We retrospectively analysed 234 patients with severe AS undergoing TAVR who had echocardiograms suitable for strain analysis. Left ventricular (LV), left atrial (LA), and right ventricular (RV) strain values were quantified pre- and post-TAVR. Chamber dysfunction was defined using consensus strain thresholds, and multichamber impairment (MCI) was defined by dysfunction in two or more chambers. A modified damage staging system incorporating strain data was compared to an established model. The association between chamber impairment and all-cause mortality was explored. Results Strain-defined chamber impairment was common, with 29% of patients exhibiting MCI. LA dysfunction was the most frequent isolated abnormality, accounting for 88% of single chamber impairment. Modest improvement was observed post-TAVR, predominantly in LV global longitudinal strain (+ 1.8 ± 3.5%, p < 0.01). MCI was associated with higher rates of atrial fibrillation, chronic kidney disease, and mitral/tricuspid regurgitation. At 12-month follow-up, patients with three-chamber impairment had significantly increased mortality risk (HR 6.84, 95% CI 1.77–26.4, p = 0.005). The modified staging system reclassified 27% of patients into higher risk categories but did not significantly improve predictive accuracy over the established model. Conclusion Multichamber dysfunction, particularly involving the LA, is prevalent in patients undergoing TAVR and confers a higher early mortality risk. While the addition of strain data improves damage detection, its incremental prognostic value over conventional models appears modest in this cohort. Larger studies are required to explore this further. Comprehensive strain imaging may nonetheless identify patients requiring closer surveillance and targeted post-TAVR therapy.
Abstract Background The ability of echocardiography (TTE) to diagnose cardiac sarcoidosis (CS) has traditionally been limited by its low sensitivity. We sought to determine the optimal TTE parameters to detect cardiac involvement in sarcoidos is with the inclusion of strain and 3DE to standard conventional TTE data. Methods Consecutive patients referred for evaluation of suspected CS were prospectively recruited and underwent symptom evaluation, 12-lead ECG, ambulatory ECG monitoring, TTE with 3DE and strain, cardiac magnetic resonance and 18F-FDG-PET. We identified the TTE phenotype most likely to identify CS. We evaluated the ability of a novel multi-parametric approach to screen for cardiac involvement among sarcoidosis patients and compared this to existing criteria. Results Of the 181 patients recruited (mean age 55 ± 11 years, 60% male, mean LVEF 57 ± 10%), 106 (59%) were diagnosed with CS. The strongest TTE parameters to predict CS were the presence of a dilated LV cavity (end-diastolic/end-systolic ≥ 71/28ml/m2 females; ≥80/32ml/m2 males), LVEF < 50%, RWMA involving multiple myocardial territories and basal septal thinning. This ‘probable CS’ TTE model had 96% specificity, 33% sensitivity and 92% PPV for the diagnosis of CS. The strain parameters most specific for a CS diagnosis were LVGLS and LVGCS greater than − 13% and − 15%, respectively. Adding strain or 3D data did not significantly improve the overall diagnostic ability of TTE. The optimal screening strategy for CS among sarcoidosis patients involved evaluation of symptoms, ECG or ambulatory ECG monitoring, and ‘probable CS’ TTE. This approach had a sensitivity of 90%, compared to 77% and 84% for the 2014 Heart Rhythm Society and 2020 American Thoracic Society criteria, respectively. In the asymptomatic patient, the absence of abnormal rhythm data and a normal TTE excluded CS in 94% of patients. Conclusion The presence of LV dilatation, LV systolic impairment, multi-territory RWMA and basal septal thinning are the most specific TTE parameters for the detection of CS. In combination with symptom evaluation and ECG data, comprehensive echocardiography remains a useful screening tool among sarcoidosis patients with suspected cardiac involvement.
Echocardiography plays a central role in the cardiovascular assessment and surveillance of patients with active cancer or in remission. With the development of specialised cardio-oncology services, the demand for echocardiography in cancer patients continues to grow. Here we explain the nuances of echocardiography in cardio-oncology, and detail how our institution has optimised service delivery to minimise cancer patient healthcare visits, improve time to cardio-toxicity diagnosis and utilising physiologists to lead cancer survivorship clinics.
