Background: Prior to left ventricular assist device implantation (LVAD), careful evaluation of the left ventricular apex (LVA) is required to exclude thrombus, as a surgical 'coring' device is used to facilitate cannula insertion. However, suboptimal imaging with unenhanced transthoracic echocardiography (UE-TTE) limits assessment for LVA thrombus. Contrast-enhanced TTE (CE-TTE) can optimise LVA imaging.

Background: Accurate evaluation of the tricuspid regurgitant maximal velocity (TRVmax) is important during transthoracic echocardiographic (TTE) evaluation for pulmonary hypertension (PHT). Contrast enhancement improves the spectral Doppler backscatter signal. However, its incremental benefit with contemporary scanners is less well established. Aim: Audit of patients who had a contrast echocardiogram (CE) using contemporary echo scanners and assess if the TR spectral Doppler envelope was improved following microsphere contrast administration compared to unenhanced imaging (UE). Methods: Retrospective analysis of patients who underwent UE then CE TR interrogation was performed. TR signal was graded 1 (clear-high level of confidence of interpretation and complete spectral Doppler envelope), 2 (sub-optimal with medium-low level of confidence of interpretation and incomplete envelope), 3 (poor-absent if no spectral Doppler signal or an unreliable or mostly incomplete spectral Doppler envelope). TRVmax was defined as the peak velocity that could be clearly identified. Results: 169 patients (males=120, mean age 57.6±15.2 years). TR assessed in RV inflow view and apical 4 chamber view. Mean heart rate 75.3±16.3. TRVmax could be be measured in 35.2% of patients with UE TTE (grade 1-2 in 119/338 clips) and in 56.2% with CE TTE (grade 1-2 in 190/338). Wilcoxon signed rank test demonstrated significant improvement (p<0.0001) in the TR spectral Doppler signal quality with CE TTE (mean score 2.11±0.87) vs. UE TTE (mean score 2.4±0.81). Mean TRVmax with UE TTE=2.54±0.48 m/s vs. CE TTE 2.6±0.43 m/s (p=0.008). Conclusion: In the era of contemporary scanners, CE TTE still improved the ability to detect and measure TRVmax.

Background: Aortic stenosis (AS) is known to cause left ventricular (LV) dysfunction and remodelling. Myocardial strain analysis can detect early myocardial dysfunction before decline in ejection fraction (EF). We aim to analyse the alteration in LV mechanics in patients with severe AS by three-dimensional (3D) speckle tracking echocardiography (STE). Methods: Fifteen symptomatic severe AS patients with normal LV systolic function (mean age 86±5 years, EF 61±11%) and 15 normal controls (mean age 68±16 years, EF 65±4%) were examined using 3D STE. Peak systolic 3D global longitudinal (GLS), global circumferential (GCS), global radial (GRS) and global area strain (GAS) were measured by independent blinded observers. LVEF was calculated using 3D echo and 2D modified Simpson's biplane method. Results: Severe AS patients had significantly reduced GLS (-9.4±3.4 vs. -19.8±1.7%, p<0.0001), GCS (-12.7±4.3 vs. -19.7±2.4%, p<0.0001), GRS (28.3±10.6 vs. 55.5±7.2%, p<0.0001) and GAS (-19.9±6.0 vs. -34.0±2.5%, p<0.0001) compared to controls. Among the 4 types of 3D global strains, GLS had the best correlation with mean aortic valve pressure gradient (r=-0.66, p=0.007), followed by GAS (r=-0.54, p=0.04), GRS (r=0.46, p=0.08) and GCS (r =-0.31, p=0.26). Receiver operator characteristics analysis revealed that GLS -9.6% was the optimal cutoff value to predict mean aortic pressure gradient >50mmHg (AUC 0.74, sensitivity 83%, specificity 67%). Conclusions: 3D global strain was significantly reduced in patients with severe AS in all axes of direction of motion. GLS was the best predictor of early myocardial dysfunction in severe AS with normal LV function.

Background: Left ventricular (LV) strain evaluation by speckle tracking echocardiography is an emerging technique for quantitative assessment of LV function. However, there is currently insufficient data about inter-vendor comparison and interpretation of results from different manufacturers. We aim to assess inter-vendor reproducibility of global and regional strain measurements. Method: Forty-nine patients (age 49 ± 20 years, EF 59 ± 11%) underwent consecutive data set acquisitions by the same operator using GE Vivid E9 and Philips IE33 ultrasound systems. Images were acquired in the standard apical four chamber, two chamber and long axis views with average heart rate of 66 ± 13 bpm and frame rate between 50 and 80 Hz. Global (GLS) and regional longitudinal peak strain values were obtained offline by two independent blinded observers using corresponding vendor specific software (EchoPAC BT11 vs. QLab 9.0). Results: Of the 49 patients, 14 were normal healthy controls. GLS demonstrated the best inter-vendor reproducibility (r = 0.89, p < 0.0001, mean difference = −1.9 ± 4.2%). Comparison for regional longitudinal strain according to segment distribution by coronary artery territories were Left anterior descending (LAD: r = 0.83, p < 0.0001, −1.9 ± 5.2%); Right coronary artery (RCA: 0.77, p < 0.0001, −1.1 ± 7.0%); and Left circumflex (LCx: r = 0.75, p < 0.0001, 1.6 ± 9.0%). The average time between the two data set acquisitions was 7:16 min. The average time required for offline analysis were significantly different between the two vendors (Philips 4.4 ± 1.3 min vs. GE 1.6 ± 0.2 min, p < 0.0001). Conclusion: There was good inter-vendor reproducibility between the GE and Philips system for GLS and regional longitudinal strain measurements but there was a significant difference in analysis time.

Background: Cardiac device-related infective endocarditis (CDRIE) is increasingly encountered and associated with high morbidity and mortality. Few trials have assessed the diagnostic accuracy of modern-era transthoracic with transoesophageal echocardiography in patients undergoing lead explantation. Aim: To determine the diagnostic accuracy of TTE using modern era imaging for detection of CDRIE. Methods: Lead explant data was reviewed for cases of cardiac device infection (CDI) since 2002. Echocardiographic findings and blood cultures for each patient were analysed to identify cases of true CDRIE, to differentiate from isolated pocket-site infection. Results: 377patients underwent lead extraction (total of 684 leads) of which 142 were for CDI, and of those, 41 cases of CDRIE. Overall, CDRIE constituted 29% of all cases of CDI. Location of device lead vegetations were: within the RA [29/35], RV [5/35], SVC [1/35]. Mean vegetation size: 14mm x 6mm. Lead vegetations were associated with concomitant valve involvement in nine cases [26%], most commonly tricuspid valve [8/9]. Isolated valve involvement was seen mostly on TV [4/6 patients] with left-sided involvement being less common [AV-1/6; MV 1/6]. Main causative organisms were Staphylococcus aureus [34%] and Staphylococcus epidermidis [20%] with culture negative [5%]. Seventeen of 35 patients underwent both TTE and TOE, of which six had CDRIE correctly diagnosed on TTE. Overall, the sensitivity of TTE for detection of lead vegetations (with or without valvular involvement) was 37%. Conclusion: TTE alone is suboptimal to exclude CDRIE due to the low sensitivity and TOE should be considered in all patients with negative TTE and clinical suspicion of lead or valvular infection.

Background: Two-dimensional left ventricular strain analysis by automated function imaging (AFI) software measures left ventricular global longitudinal strain (GLS). Reproducibility of strain analysis using this technique between expert and novice observers remains unclear. In this study, LV strain analysis and time required to complete analysis by an expert observer was compared with a novice observer. Methods: Thirty patients (age 42 ± 20 years, EF 62 ± 9%) underwent transthoracic echocardiography imaging. Images were acquired using a GE Vivid E9 system. Focused apical long axis, four-chamber and two-chamber views of three beats at a frame rate of 40–70 frames/s were obtained. Offline analysis was performed using EchoPAC. LV GLS was measured by an independent, blinded expert observer, compared to an independent, blinded novice observer. Observers recorded the time taken to perform analysis. Statistical analysis was performed using Bland Altman analysis (mean differences ±2 SD) and Pearson's correlation (r). Results: There was excellent reproducibility of LV GLS between the expert and novice observer (r = 0.96, p < 0.0001, mean difference = 0.2 ± 2). There was no significant difference in mean GLS between the two observers (−20 ± 3.9% vs. −21 ± 3.7%, p = 0.2). However, the average time taken for strain analysis was significantly different (expert 1.6 ± 0.3 min vs. novice 2.3 ± 0.8 min, p < 0.0001). Conclusion: Excellent reproducibility of GLS measurements between expert and novice observer using automated AFI software suggests potential for widespread application.

Background: The diagnosis of infective endocarditis(IE) is usually confirmed using echocardiography. However, there is little published data comparing the sensitivity of transthoracic echocardiography (TTE) and transoesophageal echocardiography(TOE) with surgical findings for the detection of right-sided IE. Aim: To determine the diagnostic accuracy of echocardiography, (both TTE and TOE) for the detection of right-sided IE. Methods: Retrospective analysis of patients with surgically confirmed right-sided endocarditis at a tertiary institution over the preceding seven years. Both TTE and TOE findings, operative notes, microbiology and demographics were analysed. Results: There were 16 patients(11 male), mean age 31years (range19-53), with a total of 21 episodes, identified with probable right-sided IE by echocardiography. The most common causative organism was Staphylococcus aureus (57%). IE type: native valve endocarditis(NVE) = 12, prosthetic valve endocarditis(PVE) = 7, mural vegetation = 2. Correlation with surgical finding in 13 cases: sensitivity for detection of right heart vegetation with TTE = 77% and TOE = 91%. TTE failed to detect one case of prosthetic tricuspid valve(TV) IE, one of prosthetic pulmonary valve IE, whilst a surgical finding of a vegetation on the RV wall was not identified by either TTE or TOE. The sensitivity of TTE and TOE for native TV IE was 100% There was one false positive for both TTE and TOE,of a previously unidentified windsock fistula that travelled from the right coronary aortic valve sinus to the right atrium and adjacent to the septal leaflet of the TV. Conclusion: TTE has a high sensitivity for the detection of right-sided NVIE, and should be considered first-line image modality in this group.

Background: Left ventricular ejection fraction (EF) is an important prognostic marker in the assessment of cardiomyopathy. We aim to determine if Three-dimensional (3D) global strain could provide an alternative marker to left ventricular function. Methods: Sixty patients underwent 2D and 3D echocardiography (4 V probe, vivid E9, GE). Simpson's biplane EF (2D-EF) and 3D-EF were measured using manual and semi-automated endocardial border tracking methods. Global longitudinal, circumferential, and radial strain were measured by 3D speckle tracking method and analysed offline by EchoPAC. Results: Fifty-one patients (mean age 75 ± 14 years; male 69%; EF 56 ± 12%, range 28–79%) were included in the analysis. Global circumferential strain had the best correlation with 2D-EF (r −0.78, p < 0.0001) and 3D-EF (r −0.78, p < 0.0001). Twenty percent of patients had a 3D-EF of <50%. ROC analysis determined global circumferential strain optimal cut-off value of <−13% predicted 3D-EF of <50% (AUC = 0.95, sensitivity 0.90, specificity 0.83) (Table 1).Table 1Pearson's Correlation of 3D Global Strain vs. 2D-EF and 3D-EF.3D Global Strain2D-EF (r)p Value3D-EF (r)p ValueLongitudinal−0.49<0.001−0.55<0.0001Circumferential−0.78<0.0001−0.78<0.0001Radial0.70<0.00010.74<0.0001 Open table in a new tab Conclusions: Three dimensional global strain is an effective method for quantifying global left ventricular systolic function. Three dimensional global circumferential strain provides the strongest correlation, suggesting the relative dominant contribution of circumferential over longitudinal myocardial shortening to overall myocardial systolic function.

Background: Transcatheter alcohol ablation of the septum in hypertrophic cardiomyopathy (TASH) is used in a selected group of patients with hypertrophic cardiomyopathy (HCM). Correct septal perforator location is confirmed with intracoronary injection of echo contrast prior to alcohol administration. This analysis sought to correlate contrast enhancement morphology with 12 month response. Methods: All peri-procedural TASH contrast (Levovist) echocardiograms were reviewed and location, area, length and width of contrast enhancement during transthoracic echocardiography (TTE) measured along with conventional parameters at baseline and 12 months post TASH. Results: Thirteen patients underwent TASH with contrast guidance. Acuson Sequoia = 8, Philips iE33 = 5. M = 9, mean age 50.8 years. Contrast specific imaging also used = 5. Mean contrast enhancement dimensions using THI (area = 4.6 cm2, length = 24.9 cm, width = 20.4 cm), LVO (area = 3.0 cm2, length = 14.6, width = 24.8 cm), MCE (area = 3.0 cm2, length = 16 cm, width = 20 cm). Mean alcohol dose = 0.9 ml, mean 24 h troponin and creatinine kinase was 25 μg/L and 602 U/L respectively. No significant correlation between any form of contrast imaging area and 24 h enzyme level. Complete echo datasets in seven patients. There was a significant difference in LVOT gradient and IVS thickness pre (85 ± 70 mmHg and 22 ± 2.6 mm respectively) and 12 month post (29 ± 27 mmHg and 19 ± 2.2 mm) TASH (p = 0.03 and p = 0.04). There was no correlation with either contrast enhancement area/length/width and reduction in LVOT gradient or reduction in septal thickness post TASH. However, in all cases, septal contrast enhancement was anatomically appropriate. Conclusion: Contrast TTE is important to guide TASH, with the anatomic location of enhancement as opposed to morphology of enhancement, predicting 12 month response.

Background: Apical hypertrophic cardiomyopathy (ApHCM) is rare disorder that is often diagnosed incidentally with transthoracic echocardiography (TTE) in patients presenting to hospital with common cardiac symptoms. ApHCM may coexist with coronary artery-left ventricular fistula (CALVF) and both conditions can cause chest pain. Aim: To determine if ApHCM may mimic an acute coronary syndrome (ACS) in patients presenting to hospital with cardiac symptoms. Methods: All cases of ApHCM diagnosed with unenhanced TTE or contrast TTE (CE) over a five year period were reviewed. Data recorded included clinical history, investigations and review of TTE findings. Results: Eighteen patients (incidence 0.02%) had a TTE diagnosis of ApHCM. Mean age 67 ± 13.6 yrs. 15/18 presented with chest pain, dyspnoea, palpitations, or a combination of these. Arrhythmias occurred in 4/18 (atrial fibrillation = 3, supraventricular tachycardia = 1). Troponin elevation in 15/18, ECG changes were praecordial deep T wave inversion in 14/18. TTE findings: ApHCM excluded using CE in two cases, apical aneurysm 1/18, apical/mid-cavity gradient 6/18, thrombus 0/18. Coronary angiography was performed in 9/18 pts of which 7/9 had no coronary disease. CE was required in three cases to make a definitive diagnosis. Two of the three CE revealed CALVF, which was confirmed on coronary angiography. Conclusion: Undiagnosed ApHCM may mimic ACS and is often diagnosed incidentally during investigation for coronary artery disease. It typically presents with ischaemic sounding chest pain, elevated troponin and significant ECG changes. The associated CALVF may contribute to these ischaemic manifestations due to coronary steal phenomenon.

Background: Tissue Doppler imaging (TDI) and 2D speckle tracking (2D) strain can potentially improve the diagnostic accuracy of dobutamine stress echocardiography (DSE) but reproducibility of these techniques is unclear. Aim: To assess reproducibility of segmental strain and velocity analysis during DSE. Methods: Eight patients (five male, age 68 ± 6.9 years) underwent DSE. Images were acquired using Vivid E9 (GE-Vingmed, Horten, Norway). Each segment was analyzed offline by two independent, blinded observers. Peak longitudinal strain and peak myocardial velocity were measured by both 2D and TDI techniques. Segments unsuitable for analysis due to suboptimal image quality were excluded. Interobserver agreement was assessed using Bland Altman analysis and Pearson's correlation (r). Results: A 384 segments were available for analysis (using a conventional 16 segment model of the left ventricle). Results are tabulated below. P < 0.0001 for all r values.Tabled 12D strain (%)2D velocity (cm/s)TDI strain (%)TDI velocity (cm/s)Rest% segments91918788Mean diff ± 2SD−0.59 ± 8.00.07 ± 1.5−0.44 ± 16.0−0.19 ± 1.2r0.720.860.590.93Low dose% segments88887874Mean diff ± 2SD−0.45 ± 9.9−0.09 ± 1.8−1.18 ± 14.0−0.12 ± 1.6r0.690.930.690.92Peak dose% segments74748484Mean diff ± 2SD−0.45 ± 8.2−0.18 ± 2.60.5 ± 18.60.9 ± 6.0r0.840.810.640.64 Open table in a new tab Conclusions: Longitudinal segmental strain and velocity measurements were highly feasible during DSE with excellent reproducibility especially for velocities. 2D strain has superior interobserver agreement compared to TDI strain during all DSE stages.

Background: Apical hypertrophic cardiomyopathy (ApHCM) is a rare variant of HCM. The differential diagnosis includes left ventricular (LV) non-compaction and prominent LV trabeculation. Contrast echocardiography (CE) can help differentiate between these and provide incremental information including assessment for LV apical thrombus and presence of associated coronary artery-LV fistulae (CALVF). Aim: To determine the role of unenhanced transthoracic echocardiography (UTTE) and CE in evaluation of ApHCM. Methods: A retrospective analysis of all TTE performed at our institution over the last five years was performed to identify patients with ApHCM. Unenhanced TTE and CE studies were reviewed, including presence or absence of CALVF or thrombus, using colour Doppler imaging and CE. Results: Of 87,374 echocardiograms performed, 22 (0.03%) had definite/possible diagnosis of ApHCM. Unenhanced TTE was sufficient alone to diagnose 14 cases. CE was required in eight cases to make a correct diagnosis: prominent trabeculation without ApHCM (n = 5), definite ApHCM (n = 2), ventricular non-compaction (n = 1). Total ApHCM cases (n = 16). The presence of apical diastolic flow on colour Doppler imaging towards the LV cavity was seen in 13/16 UTTE, consistent with CALVF. Both CE studies confirming ApHCM demonstrated presence of multiple CALVF (concordant with coronary angiography). Nine in sixteen underwent coronary angiography; no evidence of coronary artery disease = 7, multiple CALVF demonstrated = 3. Conclusion: ApHCM is a rare condition and colour Doppler and CE imaging can be helpful in its diagnosis by improving the visualisation of ventricular morphology with the incremental benefit of visualising CALVF. The selected use of CE for equivocal cases of ApHCM can improve diagnosis by TTE.