Background:Functionally significant coronary artery disease (CAD) leads to myocardial perfusion deficits and cardiac dysfunction. Quantitative flow ratio (QFR) allows accurate assessment of functional stenosis without the need for pressure wire or adenosine. Traditional transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) are commonly used to evaluate myocardial structure and function. This study aimed to evaluate and compare the diagnostic value of TTE and STE in identifying functionally significant coronary stenosis. Methods:A total of 112 hospitalized patients with suspected CAD underwent QFR assessment. Patients were divided into two groups based on QFR (QFR ≤0.8 and >0.8). TTE and STE were performed within 24 hours prior to coronary angiography. Logistic regression and receiver operating characteristic (ROC) curve analyses were used to evaluate the diagnostic performance of echocardiographic parameters. Results:Compared to the QFR >0.8 group, patients in the QFR ≤0.8 group showed significantly higher interventricular septal thickness (IVS, P=0.007), posterior wall thickness (P=0.038), and left ventricular mass index (LVMI, P=0.006). Basal longitudinal strain (Basal LS) was significantly lower in the QFR ≤0.8 group (P=0.008). Multivariate logistic regression identified Basal LS as an independent predictor of functionally significant CAD [odds ratio (OR) =1.148, P=0.039]. ROC analysis revealed comparable diagnostic performance for Basal LS [area under the curve (AUC) =0.634, P=0.016], IVS (AUC =0.653, P=0.005), and LVMI (AUC =0.683, P=0.001), with no statistically significant difference among them (all P>0.05). Conclusions:Basal LS is independently associated with functionally significant CAD. However, its diagnostic efficacy is limited and comparable to structural parameters such as IVS and LVMI. Combining STE with other imaging modalities, such as myocardial contrast echocardiography, may improve diagnostic accuracy.

Abnormal left ventricular (LV) mechanics may adversely affect the mechanical function of other chambers as heart failure with preserved ejection fraction (HFpEF) progresses. This study aimed to explore the atrioventricular and ventricular mechanical interdependence and compare the diagnostic and prognostic value of myocardial mechanics in HFpEF patients. A total of 170 patients were classified into HFpEF group (n = 90, scores ≥ 5 points) and suspected HFpEF group (n = 80, between 2 and 4 points) according to the HFA-PEFF scoring system. Strain parameters of the left atrium (LA), right atrium (RA), left ventricle (LV), and right ventricle (RV), as well as strain coupling indices, were analyzed using automated function imaging. Compared to the suspected HFpEF group, HFpEF patients showed worse biventricular systolic function and bi-atrial reservoir and conduit function. In HFpEF patients, lower LV global longitudinal strain (LVGLS) was significantly associated with impaired RV and RA strain (all p < 0.05), but not with LA strain. In suspected HFpEF patients, most results were opposite, except for RV global strain. LA reservoir strain (LASr) showed the highest diagnostic accuracy (area under the curve = 0.802), while the LASr/LVGLS ratio showed the best prognostic value (C-index = 0.670), with reduced ratios predicting adverse outcomes. Impaired LVGLS was independently associated with RV and RA dysfunction in HFpEF, but only associated with LA mechanical impairment in the early stages. LASr outperformed LVGLS for diagnosis, while the LASr/LVGLS ratio provided the best prognostic value, underscoring the relevance of interchamber mechanical coupling in HFpEF evaluation.

Background:Carotid ultrasound is a helpful approach for classifying cardiovascular risk. Quantitative flow ratio (QFR) is used to evaluate functionally significant coronary artery stenosis (CAS). The aim of this prospective study was to investigate the correlation between carotid artery features from carotid ultrasound and functionally significant CAS. Furthermore, this study aimed to evaluate the diagnostic performance of carotid ultrasound in diagnosing functional CAS. Methods:Carotid ultrasound was performed in 82 patients with suspicious coronary artery disease, measuring carotid intima-media thickness (IMT), internal artery diameter (IAD), and carotid plaques. QFR values were measured in all patients, and functionally significant CAS was defined as QFR ≤0.8. Forty patients (48.8%) had non-functionally significant CAS with QFR >0.8, while 42 patients (51.2%) had functionally significant CAS with QFR ≤0.8. Logistic regression analyses were performed to evaluate the association among functionally significant CAS, carotid ultrasound features and clinical parameters. A receiver operating characteristic (ROC) curve was developed to assess the capability of carotid ultrasound to diagnose functionally significant CAS. Results:Patients with functionally significant CAS (QFR ≤0.8) had greater IMT, carotid bifurcation IAD and internal carotid artery-IAD, compared to patients with non-functionally significant CAS, with P values of <0.001, 0.015, and 0.011, respectively. The presence of carotid plaque was significantly higher in the functionally significant CAS group (95.2%) compared to the non-functionally significant CAS group (60%), with a P value of <0.001. In multivariable logistic regression analysis, maximum plaque height (MPH) (OR: 1.777, P=0.018) was associated with functionally significant CAS in patients with coronary artery disease. ROC curves showed plaque area to be superior to IMT, MPH and plaque length in identifying functionally significant CAS. The cutoff value of the plaque area was 9.07, and the sensitivity and specificity were 85.7% and 70.0%. Conclusions:Carotid artery properties measured by carotid ultrasound were associated with functionally significant CAS. Plaque area is the most clinically useful parameter for detecting functionally significant CAS compared to IMT, MPH, and plaque length.

Background Intracardiac echocardiography (ICE) provides accurate left atrial (LA) anatomical information in the procedure of atrial fibrillation (AF) ablation but lacks LA functional assessment. LA reservoir strain (LASr) is an excellent marker of LA reservoir function. This study aimed to assess the agreement between LASr derived from ICE and transthoracic echocardiography (TTE) in AF patients and analyze the reproducibility of LASr assessed by ICE combined with speckle tracking imaging. Methods This study prospectively enrolled 110 patients with a clinical diagnosis of AF who were ready for AF ablation, including 71 patients with paroxysmal AF and 39 with persistent AF. TTE and ICE examinations were performed on each individual before AF ablation. LASr measurements derived from ICE and TTE images were using dedicated LA-tracking software. Pearson correlation coefficients (r) and Bland–Altman plots were used to evaluate the agreement of LASr between the two modalities. Intraclass correlation coefficients (ICCs) were used to assess intra- and inter-observer reproducibility. Results The agreement between LASr obtained from ICE and TTE, especially between LASr LPV (LASr derived from LA left pulmonary vein view of ICE) and LASr TTE (LASr derived from TTE) were good in both paroxysmal and persistent AF patients [ r = 0.890 ( P < 0.001) for overall population; r = 0.815 ( P < 0.001) and Bias ± LOA: -0.3 ± 9.9% for paroxysmal AF; r = 0.775 ( P < 0.001) and Bias ± LOA: -2.6 ± 3.9% for persistent AF, respectively]. But the values of LASr derived from ICE were slightly lower than those of TTE, especially in patients with persistent AF. The ICCs for LASr derived from ICE were excellent (all ICCs > 0.90). Conclusions In patients with AF, LASr derived from ICE demonstrated excellent reproducibility and showed good agreement with LASr obtained from TTE. Obtaining LASr from ICE images may be a supplementary method to evaluate LA reservoir function in AF patients and expands the potential of ICE in the field of cardiac function assessment. Graphical Abstract

Background and Objective: Localization of the left ventricle (LV) in echocardiography is important for the diagnosis of cardiovascular diseases. Previous deep learning approaches leverage semantic segmentation models to perform LV or myocardium segmentation and extract important LV parameters from the binary segmen-tation masks. Although these algorithms yield promising segmentation results, their per-pixel classification characteristic and complex postprocessing process of the binary masks compromise their robustness and speed.Methods: In this paper, inspired by the DeepSnake algorithm in the computer vision community, we develop a deep learning model called LVSnake for left ventricle localization. Our model generates the initial contour by connecting three key landmarks of the left ventricle output by our model including the start point, the apex point, and the end point of the endocardium. Then, a contour adjustment module is designed to refine the initial contour coordinates so as to obtain the final position of the endocardium. The extracted endocardium coordinates are used to perform Myocardial Infarction (MI) detection.Results: Experiment results on the HMC-QU dataset indicate that our model performs more favorably against previous approaches in terms of localization accuracy and robustness. The overall Endpoint-Error (EPE) of our model reaches 3.4 pixels. Using ventricular endocardium location extracted by our method to perform MI detection, the classification accuracy reaches 83.1% which exceeds that of existing studies (79.2%).Conclusions: Our proposed LVSnake can robustly and accurately extract LV positions from echocardiography, which can be used for MI detection.

BACKGROUND:Myocardial layer-specific strain can identify myocardial ischemia. Global myocardial work efficiency (GWE) based on non-invasive left ventricular (LV) pressure-strain loops is a novel parameter to determine LV function considering afterload. The study aimed to compare the diagnostic value of GWE and myocardial layer-specific strain during treadmill exercise stress testing to detect significant coronary artery disease (CAD) with normal baseline wall motion.METHODS:Eighty-nine patients who referred for coronary angiography due to suspected of CAD were included. Forty patients with severe coronary artery stenosis were diagnosed with significant CAD, and 49 were defined as non-significant CAD. Stress echocardiography was performed 24 h before angiography. Layer-specific longitudinal strains were assessed from the endocardium, mid-myocardium, and epicardium by 2D speckle-tracking echocardiography. Binary logistic regression analyses were performed to evaluate the association between significant CAD and echocardiographic parameters. A receiver operating characteristic curve was used to assess the capability of layer-specific strain and GWE to diagnose significant CAD.RESULTS:Patients with significant CAD had the worse function in all three myocardial layers at peak exercise compared with those with non-significant CAD when assessed with global longitudinal strain (GLS). At the peak exercise and recovery periods, GWE was lower in patients with significant CAD than in patients with non-significant CAD. In multivariable binary logistic regression analysis, peak endocardial GLS (OR: 1.35, p = 0.006) and peak GWE (OR: 0.76, p = 0.001) were associated with significant CAD. Receiver operating characteristic curves showed peak GWE to be superior to mid-myocardial, epicardial, and endocardial GLS in identifying significant CAD. Further, adding peak GWE to endocardial GLS could improve diagnostic capabilities.CONCLUSIONS:Both GWE and endocardial GLS contribute to improving the diagnostic performance of exercise stress echocardiography. Furthermore, adding peak GWE to peak endocardial GLS provides incremental diagnostic value during a non-invasive screening of significant CAD before radioactive or invasive examinations.

例1患者女性,29岁,孕1产0,宫内孕15+5周,因发现盆腔囊性包块近1个月就诊,查体:腹软,轻度隆起,孕15周大小.辅助检查:血清甲胎蛋白(alpha fetoprotein,AFP)50.03 ng/ml,绒毛膜促性腺激素 195 842.07 mIU/ml,其他肿瘤标志物均在正常范围.超声所见:子宫增大,宫腔内可见一成形胎儿,可见胎心搏动.在子宫右后方可见混合回声,大小11.5cmX8.5cmX6.4cm,内见团块状中等回声,大小约6.0cmX4.0cm,内见数个分隔,彩色多普勒血流成像示:中等回声内见少许散在短条状血流(图1).超声提示:宫内中孕,子宫右后方囊实性肿物,考虑妊娠合并卵巢肿瘤.行全身麻醉下腹腔镜右卵巢附件切除术.术中所见:右侧卵巢增大,呈直径11.0 cm囊实性肿物,外表光滑,其中一囊腔已自发破裂,破口 1.0 cm.囊内液淡黄色清亮,吸净囊内液后见囊内生乳头,右侧输卵管外观未见明显异常.术后病理诊断:(右附件)卵巢未成熟畸胎瘤(Ⅲ级).免疫组织化学染色结果:细胞角蛋白(AE1/AE3)阳性,CD99阴性,上皮细胞膜抗原(EMA)阳性,胶质纤维酸性蛋白(GFAP)阳性,细胞增殖Ki-67指数50％,生殖细胞肿瘤标志物SALL-4部分阳性,神经纤维来源肿瘤局灶阳性,S-100蛋白阳性.术后未予化疗,后足月妊娠至40周剖宫产一健康活男婴,现已规律随访5年,未见明确转移及复发征象.

Background: Myocardial work (MW) derived from the left ventricular pressure-strain loop is a novel and noninvasive method for assessing left ventricular function that accounts for loading conditions. We aimed to explore whether global MW combined with treadmill exercise stress could detect significant coronary artery disease (CAD) in patients with angina pectoris. Methods: Eighty-five patients with angina pectoris and no prior CAD history were included. All patients underwent treadmill exercise stress echocardiography and coronary angiography. Global MW was constructed from speckle-tracking echocardiography indexed to the brachial systolic blood pressure. The association between MW parameters and the presence of significant CAD was assessed with logistic regression. The discriminative power of MW parameters to detect CAD was assessed with receiver operative characteristic curve, net reclassification improvement, and integrated discrimination improvement analysis. Results: Twenty-five patients had a positive exercise echocardiogram, while significant coronary artery stenosis (>_70% in one or more major epicardial vessels or >_50% in the left main coronary artery) was observed in 41 patients. The global wasted work (GWW) and global work efficiency (GWE) were significantly higher or lower, respectively, in patients with significant CAD compared with those of nonsignificant CAD at the peak exercise and during recovery periods (P < .05 for all). Multivariate logistic regression analysis demonstrated that peak GWE and recovery GWW could predict significant CAD. Peak GWE had the highest area under the receiver operating characteristic curve (AUC) among all global MW parameters (AUC = 0.836). Furthermore, a model comprising peak GWE and recovery GWW performed better for the identification of significant CAD than peak GWE alone (AUC = 0.856). Conclusions: Peak GWE could detect significant CAD. The new model, incorporating peak GWE and recovery GWW, not only identified but also provided additional value for estimating the probability of significant CAD. Global MW parameters combined with exercise stress perform as an accurate noninvasive screening before the invasive diagnostic technique. (J Am Soc Echocardiogr 2022;35:247-57.)

Objective:To investigate the multimodality imaging features of cardiac myxoma (CM) and explore the multimodality diagnosis model of CM.Methods:One hundred and seventy-eight patients who were initially screened for CM by two-dimensional transthoracic echocardiography at Fuwai Hospital from July 2016 to August 2019 were retrospectively included in our study. Using pathological results as the gold standard, the subjects were divided into either a CM group or a non-CM group.The CM group was further divided into a typical CM subgroup and an atypical CM subgroup according to the characteristics of echocardiography. The clinical characteristics and the imaging features of echocardiography, multi-slice computed tomography (MSCT), and cardiac magnetic resonance imaging (CMR) were compared between groups by t-test, chi-squared test, or Fisher's exact test.Results:Of the 178 patients with an initial diagnosis of CM, 160 (89.9%) underwent surgical treatment and pathological examination (89.9%); 150 patients were diagnosed with CM, 1 with low-grade fibromyxoid sarcoma, 1 with undifferentiated pleomorphic sarcoma, 1 with angiosarcoma, 2 with hemangioma, 2 with lipoma, and 3 with thrombosis. The diagnostic accuracies of echocardiography, MSCT, and CMR were 93.8 %, 96.3%, and 100%, respectively. The proportions of patients with hypertension and atrial fibrillation in the typical CM subgroup were significantly lower than those of the atypical CM subgroup (25.4% vs 53.1%, χ2=8.978, P=0.003; 2.5% vs 18.8%; χ2=9.027, P=0.003); the left atrial anteroposterior diameter and the early diastolic peak flow velocity of the mitral valve were significantly higher in the typical CM subgroup than in the atypical CM subgroup [(39.21±6.34) mm vs (35.92±5.72) mm, t=2.357, P=0.020; (1.59±1.67) m/s vs (0.90±0.25) m/s; t=2.040; P=0.043]. The average long diameter of atypical CM was significantly smaller than that of typical CM [(34.81±17.43) mm vs (45.99±16.73) mm; t=3.324, P=0.001], and the width of tumor pedicle or base was significantly larger than that of typical CM [(13.02±7.28) mm vs (9.97±4.73) mm; t=-2.506, P=0.014]. The distribution, attachment site, morphology, mobility, presence of tumor pedicle, and presence of atrioventricular valve orifice obstruction in atypical CM were significantly different from those in typical CM (P＜0.05 for all). Low-attenuation was the main MSCT feature of atypical CM, and the proportion of patients with medium or mixed attenuation and enhancement was higher than that of typical CM, but the difference was not statistically significant (P＞0.05). The signal intensity of atypical CM on T1 and T2 weighted images was similar to that of typical CM (both P＞0.05). The average long diameter of the non-CM masses was smaller than that of typical CM, but the difference was not statistically significant (P＞0.05). The average short diameter was similar to the typical CM, and the width of the tumor pedicle or base was significantly larger than that of the typical CM [(13.35±6.80) mm vs (9.97±4.73) mm; t=-2.026, P=0.046]. The distribution, attachment site, morphology, presence of tumor pedicle, and mobility of non-CM masses were significantly different from those of typical CM (P＜0.05 for all). Based on the above analysis, the echocardiographic characteristics of non-CM masses were similar to those of atypical CM. The main MSCT feature of non-CM masses was mixed attenuation, which was different from that of typical CM (P＜0.05). The non-CM masses were iso-hyperintense on T1-weighted images and hyperintense on T2-weighted images, and showed enhancement at about one-half of cases on first-pass perfusion imaging and late gadolinium enhancement imaging, which did not show significant difference from those of typical CM (P＞0.05 for all).Conclusion:Based on the multimodality imaging features of CM, echocardiography should be used to discriminate typical CM from atypical CM and further cardiac CT and CMR are used to distinguish between malignant and benign tumors and to assess histological types of cardiac masses considered as atypical CM, which can improve the diagnostic efficiency of CM, reduce the misdiagnosis rate, and contribute to preoperative planning.

人工智能的概念早在19世纪20年代就已提出,随后人工智能技术得到快速发展,近几十年开始应用于医疗领域[1].随着人工智能的价值逐渐被认可,相关研究的数量日益增多.医学影像专业由于具有信息和图像数字化获取的特点而成为人工智能研究的热点学科.其中计算机断层扫描(computer tomography,CT)和磁共振成像(magnetic resonance imaging,MRI)相关研究较多,而对超声医学尤其超声心动图检查的关注较少.因此本文针对人工智能在超声心动图中的应用现状与进展作一综述.

目的:初步探究正常成年人静息及负荷状态下采用超声心动图新技术——左心室压力应变环(PSL)无创评估心肌做功参数特征且进行重复性检验.方法:纳入2019年7月至12月在中国医学科学院阜外医院体检的健康志愿者64名,平均年龄(51±14)岁,男性占48％.其中38名研究对象(男性占50％)接受平板运动负荷试验.采集并储存被检者静息及负荷状态超声心动图动态图像,运用PSL无创评估心肌做功,进行整体做功指数(GWI)、整体做功效率(GWE)、整体有效做功(GCW),整体无效做功(GWW)分析.结果:静息状态男性GWW值大于女性,GWI、GCW和GWE值小于女性,但差异均无统计学意义(P均>0.05).总人群负荷状态GWI、GCW、GWW值显著大于静息状态,GWE显著小于静息状态(P均<0.05);男性负荷状态GWI、GCW、GWW值大于静息状态(P均<0.05);女性负荷状态GWI、GCW、GWW值大于静息状态,GWE值小于静息状态(P均<0.05);负荷状态男性GWW值显著低于女性(P<0.05).GWW、GWI、GCW和GWE值在不同年龄段间差异均无统计学意义(P均>0.05).组内相关系数和Bland-Altman图显示静息及负荷状态下心肌做功参数在观察者内及观察者间一致性良好.结论:研究初步探究了正常成人静息及负荷状态下PSL无创评估心肌做功参数特征,进一步验证了心肌做功参数具有良好的重复性.