Opioid cardiotoxicity is an increasing clinical concern, yet its echocardiographic manifestations are heterogeneous and poorly characterized. This narrative review synthesizes available evidence, maps the principal echocardiographic phenotypes of opioid-related cardiac injury, and identifies major knowledge gaps. A structured PubMed search (January 2014-December 2024) combined opioid and echocardiographic terms without language restriction. Human and animal studies of any design assessing cardiac structure or function by echocardiography after acute or chronic opioid exposure were eligible. Of 209 records, 41 were included and grouped by dominant phenotype. No formal protocol (e.g., PRISMA) or risk-of-bias appraisal was applied. Five distinct—and often conflicting—phenotypes emerged: (1) severe, potentially reversible global left ventricular systolic dysfunction (LVEF as low as 20
Left ventricular ejection fraction (LVEF) often remains normal in cardiac amyloidosis (CA) because declines in stroke volume (SV) parallel reductions in end-diastolic volume. The myocardial contraction fraction (MCF), the ratio of SV to myocardial volume, has been proposed as superior to LVEF in predicting mortality in CA. Thirty patients with confirmed CA underwent echocardiography and were followed for a mean of 18.2 ± 5.8 months. MCF was calculated from standard two-dimensional echocardiographic measurements. Cox proportional hazards modeling with Lasso-penalized selection was used to evaluate the association of MCF with all-cause mortality. Mean age was 70.1 ± 8.6 years; 76.7
Anomalous insertion of the papillary muscle (APM) into the mitral valve leaflet is a rare congenital abnormality of the subvalvular apparatus. Most published reports describe direct papillary muscle insertion in association with obstructive physiology, particularly in hypertrophic cardiomyopathy (HCM), where it contributes to left ventricular outflow tract (LVOT) obstruction and systolic anterior motion (SAM)–related mitral regurgitation. However, similar papillary muscle–leaflet continuity may also serve as a primary mechanical determinant of valve dysfunction in patients without a clinical diagnosis of HCM. This review synthesizes published reports of APM insertion across different clinical contexts and interprets them within a mechanism-oriented framework based on LVOT dynamics and functional role of the papillary muscle rather than disease labels. Available reports indicate a heterogeneous clinical spectrum in which hemodynamic manifestations reflect interactions among papillary muscle anatomy, mitral valve mechanics, and ventricular geometry. Although LVOT obstruction remains an important presentation, many cases show predominant mitral regurgitation due to leaflet tethering or, less commonly, functional mitral stenosis from impaired diastolic leaflet opening. These phenotypes arise from subvalvular mechanical restriction rather than primary leaflet pathology. Echocardiography plays a central role in diagnosis, yet APM insertion may be overlooked if assessment focuses primarily on leaflet morphology or Doppler findings. Transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging provide complementary anatomical detail for accurate characterization and surgical planning. Greater awareness of this geometry-based interaction and adoption of a structured imaging approach may reduce diagnostic oversight and improve decision-making in patients with atypical mitral valve dysfunction.
Improvement in left ventricular ejection fraction (LVEF) after transcatheter aortic valve replacement (TAVR) has been associated with better clinical outcomes, but predictors of recovery remain poorly defined. This study aimed to identify echocardiographic parameters associated with post-TAVR LVEF improvement in patients with severe aortic stenosis (AS) and reduced LVEF. Among 1,133 consecutive patients who underwent TAVR between December 2013 and June 2024, 128 with baseline LVEF < 50
Paravalvular leak (PVL) after surgical valve replacement may cause heart failure, hemolytic anemia, or both. Transcatheter closure is an important therapeutic option for selected patients at high surgical risk. The irregular and often complex anatomy of PVL requires imaging assessment throughout patient selection, procedural planning, device deployment, and follow-up. Transthoracic echocardiography assesses prosthetic valve function and the hemodynamic consequences of PVL. Transesophageal echocardiography, particularly three-dimensional imaging with color Doppler, characterizes defect anatomy and guides wire crossing, device positioning, and release decisions. Assessment must address residual regurgitation, device stability, and potential interference with prosthetic valve function. Therapeutic goals depend on the dominant clinical phenotype. In heart failure-dominant PVL, sufficient reduction of regurgitant burden may improve symptoms and hemodynamics despite a small residual leak. In hemolysis-dominant PVL, residual high-velocity jets may sustain hemolysis and require additional closure. Mixed presentations require assessment of both hemodynamic and hematologic responses. Cardiac computed tomography complements echocardiography by defining channel geometry and fluoroscopic working projections, particularly when acoustic shadowing limits visualization. This review summarizes periprocedural echocardiographic assessment, emphasizing the integration of anatomical findings, clinical phenotype, and treatment response to guide procedural decisions and follow-up.
