Pericardial diseases have gained renewed clinical interest, leading to a renaissance in the field. There have been many recent advances in pericardial diseases in both multimodality cardiac imaging of diagnoses, such as recurrent, transient constrictive and effusive-constrictive pericarditis, and targeted therapeutics, especially anti-interleukin (IL)-1 agents that affect the inflammasome as part of autoinflammatory pathophysiology. There remains a large educational gap for clinicians, leading to variability in evaluation and management of these patients. The latest pericardial imaging (American Society of Echocardiography, European Association of Cardiovascular Imaging) and clinical guidelines (European Society of Cardiology) are >8-10 years of age and may not reflect current practice. Recent clinical trials involving anti-IL-1 agents in recurrent pericarditis, including anakinra (AIRTRIP), rilonacept (RHAPSODY), and goflikicept have demonstrated their efficacy. The present document represents an international position statement from world leaders in the pericardial field, focusing on novel concepts and emphasizing the role of multimodality cardiac imaging as well as new therapeutics in pericardial diseases. (c) 2024 by the American College of Cardiology Foundation.

Introduction: Myocardial strain, a marker of heart muscle deformation, is crucial for assessing cardiac function and prognosis in cardiovascular diseases. Speckle Tracking Echocardiography (STE) is the preferred non-invasive method for strain. However, STE's accuracy can vary due to image quality, vendor-dependence, and operator inconsistency. STE-derived Global Longitudinal Strain (manual GLS) changes are key in early detection of cancer treatment-related cardiotoxicity. Hypothesis: We hypothesized that AI-derived GLS would have a stronger correlation with all-cause mortality (ACM) than STE-derived GLS. Methods: We retrospectively analyzed 1,224 echocardiograms, from 762 patients, with STE GLS values from Harrington Heart and Vascular Institute Cardio-Oncology studies performed between Jan 2021 - Jun 2022. Images were analyzed using EchoGo Core (Ultromics Ltd), a cloud-based, AI-powered software employing convolutional neural networks. Pearson's correlation coefficients and Bland-Altman analysis compared STE and AI-derived GLS (R-Studio). Both methods were evaluated using Receiver Operating Characteristic (ROC) curves. Patients were divided into tertiles based on their GLS values to assess ACM hazard ratios (HR). Results: Out of 762 patients, a moderate correlation (r=0.63, p<0.001) existed between STE and AI-derived GLS. The mean difference between the two was 2.37 and the limits of agreement were -3.65 to 8.39. The Area Under the Curve (AUC) was higher for AI (0.66) than STE GLS (0.59). Over an average follow-up of 215 days (± 169 days), 26 deaths occurred. When Tertile 3 was compared to Tertile 1, AI-derived GLS showed an HR of 4.46 (p=0.023), whereas the STE GLS HR was not statistically significant (HR=2.4). Conclusions: The study showed moderate agreement between AI and manual GLS measurements. The HR for ACM was statistically significant only in AI-derived GLS in patients undergoing cardiotoxic chemotherapy.

Purpose of ReviewThe objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.Recent FindingsRecent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause.Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

Spontaneous native mitral valve leaflet thrombosis is an exceedingly rare phenomenon. Here, we describe the case of a 71-year-old woman with rheumatic mitral stenosis who presented with cardiogenic shock. She was found to have a thrombus on her native mitral valve despite being on anticoagulation and without a clear associated hypercoagulable comorbidity. The patient underwent mitral valve replacement with favorable outcomes. This case sheds light on the inflammatory and prothrombotic nature of rheumatic valvular disease.

A resurgence of interest in atrial function has enhanced our understanding of the atrial contributions to cardiovascular performance in health and disease. Despite this attention, quantifying atrial function is difficult, in part because the atria are geometrically complex and because of the critical interplay between the cardiac cycle-dependent atrial functions and ventricular performance. The primary mechanical function of the left atrium (LA) is to modulate left ventricular filling and cardiovascular performance, a task that is accomplished by its interrelated atrial roles as a reservoir for pulmonary venous flow during ventricular systole, as a conduit for pulmonary venous flow during early ventricular diastole, and as a booster pump that increases ventricular filling during late ventricular diastole. This chapter will discuss these cycle-dependent functions in the context of normal LA physiology, ventricular systolic and diastolic dysfunction, and primary atrial myocardial disease using the LA pressure-volume relation, conventional methods, and deformation analysis.

ObjectivesTo examine the relationship between pericardial fat (PCF) and cardiac structure and function among HIV-infected patients in the sub-Saharan African country of Uganda. People living with HIV (PLHIV) have altered fat distribution and an elevated risk for heart failure. Whether altered quantity and radiodensity of fat surrounding the heart relates to cardiac dysfunction in this population is unknown.MethodsOne hundred HIV-positive Ugandans on antiretroviral therapy were compared with 100 age and sex-matched HIV-negative Ugandans; all were >45 years old with >1 cardiovascular disease risk factor. Subjects underwent ECG-gated non-contrast cardiac CT and transthoracic echocardiography with speckle tracking strain imaging. Multivariable linear and logistic regression models were used to explore the association of PCF with echocardiographic outcomes.ResultsMedian age was 55% and 62% were female. Compared with uninfected controls, PLHIV had lower body mass index (27 vs 30, p=0.02) and less diabetes (26% vs 45%, p=0.005). Median left ventricular (LV) ejection fraction was 67%. In models adjusted for traditional risk factors, HIV was associated with 10.3 g/m2higher LV mass index (LVMI) (95% CI 3.22 to 17.4; p=0.005), 0.87% worse LV global longitudinal strain (GLS) (95% CI −1.66 to −0.07; p=0.03) and higher odds of diastolic dysfunction (OR 1.96; 95% CI 0.95 to 4.06; p=0.07). In adjusted models, PCF volume was significantly associated with increased LVMI and worse LV GLS, while PCF radiodensity was associated with worse LV GLS (all p<0.05).ConclusionsIn Uganda, HIV infection, PCF volume and density are associated with abnormal cardiac structure and function.

Objective The aim of the study was to study the feasibility, safety, and efficacy of transesophageal echocardiography–guided intraoperative left ventricular lead placement via a video-assisted thoracoscopic surgery approach in patients with failed conventional biventricular pacing. Methods Twelve patients who could not have the left ventricular lead placed conventionally underwent epicardial left ventricular lead placement by video-assisted thoracoscopic surgery. Eight patients had previous chest surgery (66%). Operative positioning was a modified far lateral supine exposure with 30-degree bed tilt, allowing for groin and sternal access. To determine the optimal left ventricular location for lead placement, the left ventricular surface was divided arbitrarily into nine segments. These segments were transpericardially paced using a handheld malleable pacing probe identifying the optimal site verified by transesophageal echocardiography. The pacing leads were screwed into position via a limited pericardiotomy. Results The video-assisted thoracoscopic surgery approach was successful in all patients. Biventricular pacing was achieved in all patients and all reported symptomatic benefit with reduction in New York Heart Association class from III to I–II (P = 0.016). Baseline ejection fraction was 23 ± 3%; within 1-year follow-up, the ejection fraction increased to 32 ± 10% (P = 0.05). The mean follow-up was 566 days. The median length of hospital stay was 7 days with chest tube removal between postoperative days 2 and 5. Conclusions In patients who are nonresponders to conventional biventricular pacing, intraoperative left ventricular lead placement using anatomical and functional characteristics via a video-assisted thoracoscopic surgery approach is effective in improving heart failure symptoms. This optimized left ventricular lead placement is feasible and safe. Previous chest surgery is no longer an exclusion criterion for a video-assisted thoracoscopic surgery approach.

HomeCirculation: Cardiovascular ImagingVol. 11, No. 10Right Ventricular Strain Comes of Age Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBRight Ventricular Strain Comes of Age Brian D. Hoit, MD Brian D. HoitBrian D. Hoit Brian D. Hoit, MD, Harrington Heart & Vascular Center, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland OH 44106–5038. Email E-mail Address: [email protected] Department of Medicine, Case Western Reserve University, Cleveland, OH. Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH. Search for more papers by this author Originally published15 Oct 2018https://doi.org/10.1161/CIRCIMAGING.118.008382Circulation: Cardiovascular Imaging. 2018;11:e008382This article is a commentary on the followingIncremental Prognostic Value of Right Ventricular Strain in Patients With Acute Decompensated Heart FailureSee Article by Hamada-Harimura et alPredicting rain doesn’t count. Building arks does1—Warren BuffettUntil relatively recently, the importance of right ventricular (RV) function was underestimated, owing largely to the success of the Fontan procedure, which functionally excludes the RV, and misinforming open pericardium canine experiments that failed to take ventricular interaction into account.2 However, it has subsequently become evident that RV function plays a critical role in both the clinical expression and the prediction of adverse cardiovascular outcomes in cardiomyopathies, and congenital, ischemic, valvular, and pulmonary heart diseases.3Despite significant developments in cardiac imaging, assessing RV structure and function remains challenging, in part because of the complicated geometry and striking load dependence of the RV. Although RV function is evaluated noninvasively with magnetic resonance (the gold standard for RV volume), radionuclide angiography and computed tomography, echocardiography is most often used because of its availability, safety, versatility, repeatability, and its ability to image in real time with high temporal and spatial resolution. Echocardiographic indices of RV function include fractional area change, tricuspid annular plane systolic excursion, tricuspid annular systolic tissue velocity, tricuspid annular isovolumic acceleration, and RV myocardial performance index; however, these methods are demanding for reasons that include the complex geometry and retrosternal location of the RV, poor endocardial definition because of prominent trabeculations, only modest correlations with cardiac magnetic resonance-measured RV ejection fraction, and the regional (versus global) nature of most ultrasound-based approaches.4 Many of these limitations are overcome by the application of deformational analysis (strain and strain rate imaging) of the RV, methodology which has generated considerable interest by investigators.Strain and strain rates represent the magnitude and rate of myocardial deformation, respectively, and are measured using either color tissue Doppler imaging or by 2-dimensional speckle-tracking echocardiography techniques. Although tissue Doppler imaging has excellent temporal resolution and optimal 2-dimensional image quality is not necessary, tissue Doppler imaging is highly dependent on the angle of insonation and signal to noise may be reduced. In contrast, 2-dimensional speckle-tracking echocardiography analyzes myocardial motion without significant angle dependency by frame-by-frame tracking of speckles, which are natural acoustic markers generated from interactions between ultrasound and myocardial tissue within a user-defined region of interest. However, good image quality is needed for accurate tracking and frame rates of ≈50 to 70 are needed to avoid speckle decorrelation.5 Most studies of RV function measure strain with 2-dimensional speckle-tracking echocardiography.The ability of chamber-specific strains to predict adverse outcomes both independently and incrementally to conventional clinical and echocardiographic variables has been demonstrated in the left ventricle (LV) and the left atrium for a wide range of cardiovascular diseases.5–8 These data and the well-recognized importance of conventional measures of RV function in risk stratification stratagems suggest that RV strain would have similar advantages. However, while recent studies suggest that RV strain is a feasible and reproducible tool in diverse patient populations,9–12 robust clinical outcome data from large prospective trials are needed to confirm the incremental predictive ability before RV strain is widely accepted. The study by Hamada-Harimura et al13 in this issue of Circulation CardiovascularImaging represents an important first step in patients hospitalized with acute decompensated heart failure (HF).Hamada-Harimura et al13 studied 692 patients hospitalized for acute decompensated HF with predischarge clinical, laboratory, and echocardiographic examinations, the latter including LV global longitudinal strain and LV global circumferential strain, and RV free wall strain (3 segments) and RV global longitudinal strain (free wall plus 3 septal segments). Strain data were acquired with 3 ultrasound platforms (GE Healthcare, Milwaukee WI; Philips Medical, Andover PA; Toshiba Medical Systems, Tochigi Japan) and analyzed at a core laboratory using vendor-independent software (TomTec Imaging Systems, Munich Germany). Seventy-four patients were excluded owing to incomplete echocardiographic data or technically inadequate images. Although data acquisition was predischarge, the precise timing relative to discharge and the duration of the index hospitalization are not well described. The primary composite end point was cardiovascular death (death because of HF, myocardial infarction, a cardiovascular procedure or hemorrhage, and sudden death) or unplanned hospitalization because of worsening HF during a median follow-up of 427 days (interquartile ratio, 203–706 days); the secondary end point was cardiovascular death. The event rate was 35%, including 81 deaths (61 because of HF) and 134 HF rehospitalizations. Not surprisingly, patients with events were older and had higher New York Heart Association class and brain natriuretic peptide; lower body mass index, hemoglobin, sodium, and estimated glomerular filtration rate; and greater use of diuretics and amiodarone than patients without events. Echocardiographically, those with events had decreased free wall and global RV strain in addition to a larger left atrial volume index, more severe secondary mitral regurgitation, increased E/e′, tricuspid regurgitant velocity, and inferior vena cava diameter, and lower tricuspid annular plane systolic excursion. Surprisingly, there were no differences in LV ejection fraction, LV global longitudinal strain and LV circumferential strain. In multivariable Cox and global χ2 models, only impaired free wall RV strain was independently and incrementally predictive of adverse events. The authors suggest that RV free wall strain may provide greater prognostic power than standard echocardiographic parameters and may be helpful for identifying vulnerable HF patients at high risk for cardiac events after discharge. While the potential prognostic value of RV strain and its feasibility and reproducibility have been reported previously,9,14,15 the present study is unique in that RV free wall and global strains were examined prospectively in a large, multicenter (11 sites in Japan) trial in a HF population that included both HF with preserved ejection fraction and HF with reduced ejection fraction and that used a blinded core laboratory. Strain measurements were highly feasible and inter- and intraobserver variability for LV and RV strains was excellent, although surprisingly, intraobserver variability for LV strains was twice that of interobserver variability.There are many limitations that should be considered when interpreting the results of this study. Specifically, selection bias may have been introduced by the exclusion of patients that died during the index admission; the duration and frequency of HF hospitalizations before the index hospitalization likely varied and may have influenced the results; the cause of HF and sex, which may affect prognosis in HF was not considered; invasive hemodynamic and cardiopulmonary exercise data were not reported; the cohort does not appear to be multiethnic; and a simple, but poor surrogate measure (color flow jet area) was used to quantify mitral regurgitation. Perhaps most importantly, left atrial reservoir strain, which has been shown to be independently associated with adverse cardiac outcomes5,16 was not reported; this is particularly important insofar as an increased left atrial volume index (along with impaired free wall RV strain) was significantly associated with cardiac events in both unadjusted and adjusted subanalyses of the 238 patients with HF with reduced ejection fraction.The study by Hamada-Harimura et al13 raises a number of important questions. First, what clinical, laboratory, and echocardiographic variables should be used to risk stratify patients with acute decompensated HF (ie, what increment of prediction is worth the additional expense and effort), and at what point of their hospitalization should testing be performed? Should a multichamber deformation imaging approach be adopted in these strategies?16 Second, what is the optimal statistical method in which to measure a true improvement in prognostic accuracy, that is, a Cox proportional analysis, which assumes the predictor variables are constant over time, or a time-dependent receiver operating characteristic analysis that does not? Although both were measured, time-dependent area under the curve data are not reported. Third, for RV strain, how many RV segments should be analyzed? While free wall and septal regions were recorded from a 4-chamber view in this study, reports of RV-focused views to assess the posterolateral wall17 and an 18 segment model using 3 RV-focused apical views appear promising.15,18 Finally, and perhaps most importantly, how can the ability to identify a cohort of HF patients at risk for cardiac death and rehospitalization be leveraged to intervene with both pharmacological and advanced therapies?Despite its theoretical advantages, deformation analysis requires expertise, highly trained operators, and the data acquisition and processing steps are relatively time consuming. Variable partition values,19,20 the variability in values between the different speckle-tracking echo algorithms, rapidly changing software, and a paucity of normative values14 remain barriers to the use of strain imaging. Recently, global RV longitudinal strain values were found to be similar in a near-simultaneous evaluation using 2 vendor specific systems (GE and Philips), but differed when they were analyzed using vendor-independent software; moreover, regional strain differences revealed large, widespread variability without systematic differences, suggesting that at the current time, global but not regional RV strains should be reported.15 Notwithstanding a compelling body of data, risk stratification and decision-making strategies incorporating RV strain are not currently exploited in routine clinical practice. The study by Hamada-Harimura et al13 provides a needed step that supports incorporation of RV strain into risk prediction that hopefully, as Warren Buffett exhorts, will lead to an action of consequence.DisclosuresDr Hoit is a speaker for Philips Medical.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circimagingBrian D. Hoit, MD, Harrington Heart & Vascular Center, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland OH 44106–5038. Email [email protected]cwru.eduReferences1. Quote by Warren Buffet, n.d. Brainyquotes.com. Accessed September 3, 2018Google Scholar2. Kagan A. Dynamic responses of the right ventricle following extensive damage by cauterization.Circulation. 1952; 5:816–823. doi: 10.1161/01.CIR.5.6.816LinkGoogle Scholar3. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure.Circulation. 2008; 117:1717–1731. doi: 10.1161/CIRCULATIONAHA.107.653584LinkGoogle Scholar4. Cameli M, Righini FM, Lisi M, Mondillo S. Right ventricular strain as a novel approach to analyze right ventricular performance in patients with heart failure.Heart Fail Rev. 2014; 19:603–610. doi: 10.1007/s10741-013-9414-7CrossrefMedlineGoogle Scholar5. Hoit BD. Left atrial size and function: role in prognosis.J Am Coll Cardiol. 2014; 63:493–505. doi: 10.1016/j.jacc.2013.10.055CrossrefMedlineGoogle Scholar6. Kalam K, Otahal P, Marwick TH. Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction.Heart. 2014; 100:1673–1680. doi: 10.1136/heartjnl-2014-305538CrossrefMedlineGoogle Scholar7. Sengeløv M, Jørgensen PG, Jensen JS, Bruun NE, Olsen FJ, Fritz-Hansen T, Nochioka K, Biering-Sørensen T. Global longitudinal strain is a superior predictor of all-cause mortality in heart failure with reduced ejection fraction.JACC Cardiovasc Imaging. 2015; 8:1351–1359. doi: 10.1016/j.jcmg.2015.07.013CrossrefMedlineGoogle Scholar8. Cho KI. Right ventricular longitudinal strain: a target indicator in the treatment of pulmonary arterial hypertension.Korean Circ J. 2015; 45:362–363. doi: 10.4070/kcj.2015.45.5.362CrossrefMedlineGoogle Scholar9. Iacoviello M, Citarelli G, Antoncecchi V, Romito R, Monitillo F, Leone M, Puzzovivo A, Lattarulo MS, Rizzo C, Caldarola P, Ciccone MM. Right ventricular longitudinal strain measures independently predict chronic heart failure mortality.Echocardiography. 2016; 33:992–1000. doi: 10.1111/echo.13199CrossrefMedlineGoogle Scholar10. Motoki H, Borowski AG, Shrestha K, Hu B, Kusunose K, Troughton RW, Tang WH, Klein AL. Right ventricular global longitudinal strain provides prognostic value incremental to left ventricular ejection fraction in patients with heart failure.J Am Soc Echocardiogr. 2014; 27:726–732. doi: 10.1016/j.echo.2014.02.007CrossrefMedlineGoogle Scholar11. Park JH, Park MM, Farha S, Sharp J, Lundgrin E, Comhair S, Tang WH, Erzurum SC, Thomas JD. Impaired global right ventricular longitudinal strain predicts long-term adverse outcomes in patients with pulmonary arterial hypertension.J Cardiovasc Ultrasound. 2015; 23:91–99. doi: 10.4250/jcu.2015.23.2.91CrossrefMedlineGoogle Scholar12. Kusunose K, Popović ZB, Motoki H, Marwick TH. Prognostic significance of exercise-induced right ventricular dysfunction in asymptomatic degenerative mitral regurgitation.Circ Cardiovasc Imaging. 2013; 6:167–176. doi: 10.1161/CIRCIMAGING.112.000162LinkGoogle Scholar13. Hamada-Harimura Y, Seo Y, Ishizu T, Nishi I, Machino-Ohtsuka T, Yamamoto M, Sugano A, Sato K, Sai S, Obara K, Yoshida I, Aonuma K; for the ICAS-HF Investigators. Incremental prognostic value of right ventricular strain in patients with acute decompensated heart failure.Circulation Cardiovascular Imaging. 2018; 11:e007249. doi: 10.1161/CIRCIMAGING.117.007249LinkGoogle Scholar14. Morris DA, Krisper M, Nakatani S, Köhncke C, Otsuji Y, Belyavskiy E, Radha Krishnan AK, Kropf M, Osmanoglou E, Boldt LH, Blaschke F, Edelmann F, Haverkamp W, Tschöpe C, Pieske-Kraigher E, Pieske B, Takeuchi M. Normal range and usefulness of right ventricular systolic strain to detect subtle right ventricular systolic abnormalities in patients with heart failure: a multicentre study.Eur Heart J Cardiovasc Imaging. 2017; 18:212–223. doi: 10.1093/ehjci/jew011CrossrefMedlineGoogle Scholar15. Il’Giovine ZJ, Mulder H, Chiswell K, Arges K, Tomfohr J, Hashmi A, Velazquez EJ, Kisslo JA, Samad Z, Rajagopal S. Right ventricular longitudinal strain reproducibility using vendor-dependent and vendor-independent software.J Am Soc Echocardiogr. 2018; 31:721.e5–732.e5. doi: 10.1016/j.echo.2018.01.008Google Scholar16. Saha SK, Luo XX, Gopal AS, Govind SC, Fang F, Liu M, Zhang Q, Ma C, Dong M, Kiotsekoglou A, Yu CM. Incremental prognostic value of multichamber deformation imaging and renal function status to predict adverse outcome in heart failure with reduced ejection fraction.Echocardiography. 2018; 35:450–458. doi: 10.1111/echo.13821CrossrefMedlineGoogle Scholar17. Mouton S, Ridon H, Fertin M, Pentiah AD, Goémine C, Petyt G, Lamblin N, Coisne A, Foucher-Hossein C, Montaigne D, de Groote P. 2D-speckle tracking right ventricular strain to assess right ventricular systolic function in systolic heart failure. Analysis of the right ventricular free and posterolateral walls.Int J Cardiol. 2017; 245:190–195. doi: 10.1016/j.ijcard.2017.07.077CrossrefMedlineGoogle Scholar18. Rajagopal S, Forsha DE, Risum N, Hornik CP, Poms AD, Fortin TA, Tapson VF, Velazquez EJ, Kisslo J, Samad Z. Comprehensive assessment of right ventricular function in patients with pulmonary hypertension with global longitudinal peak systolic strain derived from multiple right ventricular views.J Am Soc Echocardiogr. 2014; 27:657.e3–665.e3. doi: 10.1016/j.echo.2014.02.001CrossrefGoogle Scholar19. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28:1.e14–39.e14. doi: 10.1016/j.echo.2014.10.003CrossrefGoogle Scholar20. Shukla M, Park JH, Thomas JD, Delgado V, Bax JJ, Kane GC, Howlett JG, White JA, Fine NM. Prognostic value of right ventricular strain using speckle-tracking echocardiography in pulmonary hypertension: a systematic review and meta-analysis.Can J Cardiol. 2018; 34:1069–1078. doi: 10.1016/j.cjca.2018.04.016CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Baysan O and Akyıldız İ (2020) Right ventricular strain, Heart, Vessels and Transplantation, 10.24969/hvt.2020.187, 4:Issue 1, (16) Ji M, Wu W, He L, Gao L, Zhang Y, Lin Y, Qian M, Wang J, Zhang L, Xie M and Li Y (2022) Right Ventricular Longitudinal Strain in Patients with Heart Failure, Diagnostics, 10.3390/diagnostics12020445, 12:2, (445) Related articlesIncremental Prognostic Value of Right Ventricular Strain in Patients With Acute Decompensated Heart FailureYoshie Hamada-Harimura, et al. Circulation: Cardiovascular Imaging. 2018;11 October 2018Vol 11, Issue 10 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.008382PMID: 30354483 Originally publishedOctober 15, 2018 KeywordsEditorialscardiomyopathiesechocardiographytomographyPDF download Advertisement SubjectsEchocardiographyHeart FailurePrognosis

Purpose of Review To review the current status of measuring left atrial functions with echocardiography and the ability of atrial functional analysis to predict cardiovascular outcomes. Recent Findings An increasing body of data suggests that left atrium (LA) function assessed with echocardiography provides incremental prognostic information in general and referral populations, and in patients with atrial fibrillation, stroke, heart failure, and ischemic and valvular heart disease. In addition to volumetric analysis and spectral and tissue Doppler, deformational (strain and strain rate) imaging has most recently been used to assess LA reservoir, conduit, and booster pump functions and predict cardiovascular events. Summary Studies of LA function provide new insights into the contribution of LA performance to cardiovascular disease and are promising tools for predicting cardiovascular events in healthy subjects and patients with heart disease. However, robust clinical outcome data from large prospective outcome trials are needed to confirm the incremental predictive ability of these LA functional measures before they are widely accepted.

PURPOSE OF REVIEW:To summarize recent literature on the use of left atrial strain in the diagnosis and management of patients with heart failure.RECENT FINDINGS:Left atrial dysfunction is a hallmark of diastolic dysfunction and heart failure, in particular, heart failure with preserved ejection fraction (HFpEF). Recently, myocardial deformation analysis via strain and strain rate measurements have been applied to the left atrium. These measurements have been shown to aid in the diagnosis of heart failure and be accurate predictors of cardiac pressures, diastolic dysfunction, exercise performance, and clinical outcomes such as cardiac hospitalizations and mortality. However, limitations related to the technical aspect of accurately imaging and tracking the thin-walled left atrium and the current lack of consensus on 'normal' reference values remain.SUMMARY:Left atrial strain represents a novel, noninvasive technique to aid in the diagnosis, prognosis, and management of patients with heart failure. Although it is not yet a part of routine clinical practice, the measurement has significant promise within this population pending further validation.

Purpose of Review The purpose of this paper is to review current approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.Recent Findings Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have refined our approaches to the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. New diagnostic and triage strategies have been proposed, and recent data have advanced our ability to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and establish its cause.Summary Despite these recent findings, there is a paucity of evidence-based data to guide the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is unquestioned, there are increasing niche roles for multimodality imaging.

The pericardium consists of a visceral mesothelial monolayer (epicardium) that reflects over the great vessels and joins an outer, relatively inelastic fibrous parietal layer of organized collagen and elastin fibers, between which is a potential space that normally contains up to 50 mL of plasma filtrate. Although not essential for life, the pericardium serves important, albeit subtle, functions in the euvolemic healthy individual that become increasingly important in hypervolemic states and conditions in which the heart enlarges acutely. The pericardial functions can be divided into the mechanical, reflex, membranous, metabolic, and ligamentous.

The resurgence of interest in left atrial (LA) size and function has heightened our awareness of the atrial contributions to cardiovascular performance. A key reason responsible for this renaissance is the increasingly recognized importance of the LA in determining prognosis and risk stratification in both the general population and in patients with a wide variety of cardiovascular pathologies. 1 Hoit D. Left atrial size and function. Role in prognosis. J Am Coll Cardiol. 2014; 63: 493-505 Abstract Full Text Full Text PDF PubMed Scopus (580) Google Scholar A considerable body of data exists to support incorporation of LA size in risk stratification schemes in patients with dilated cardiomyopathy (DCM). 2 Takemoto Y. Barnes M.E. Seward J.B. Lester S.J. Appleton C.A. Gersh B.J. et al. Usefulness of left atrial volume in predicting first congestive heart failure in patients or ≥65 years of age with well-preserved left ventricular systolic function. 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Independent relationship of left atrial size and mortality in patients with heart failure: an individual patient meta-analysis of longitudinal data (MeRGE Heart Failure). Eur J Heart Fail. 2009; 11: 929-936 Crossref PubMed Scopus (125) Google Scholar , 6 Rossi A. Cicoira M. Zanolla L. Golia G. Franceschini L. Brighetti G. et al. Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol. 2002; 40: 1425 Abstract Full Text Full Text PDF PubMed Scopus (287) Google Scholar , 7 Tamura H. Watanabe T. Nishiyama S. Sasaki S. Arimoto T. Takahashi H. et al. Increased left atrial volume index predicts a poor prognosis in patients with heart failure. J Card Fail. 2011; 17: 210-216 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar , 8 Ristow B. Ali S. Whooley M.A. Schiller N.B. Usefulness of left atrial volume index to predict heart failure hospitalization and mortality in ambulatory patients with coronary heart disease and comparison to left ventricular ejection fraction (from the Heart and Soul Study). Am J Cardiol. 2008; 102: 70-76 Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar , 9 Suh I.W. Song J.M. Lee E.Y. Kang S.H. Kim M.J. Kim J.J. et al. Left atrial volume measured by real-time 3-dimensional echocardiography predicts clinical outcomes in patients with severe left ventricular dysfunction and in sinus rhythm. J Am Soc Echocardiogr. 2008; 21: 439-445 Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar LA size predicts the development of new heart failure (HF) irrespective of left ventricular (LV) systolic function 2 Takemoto Y. Barnes M.E. Seward J.B. Lester S.J. Appleton C.A. Gersh B.J. et al. Usefulness of left atrial volume in predicting first congestive heart failure in patients or ≥65 years of age with well-preserved left ventricular systolic function. Am J Cardiol. 2005; 96: 832-836 Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar , 3 Gottdiener J.S. Kitzman D.W. Aurigemma G.P. Arnold A.M. Manolio T.A. Left atrial volume, geometry, and function in systolic and diastolic heart failure of persons or ≥ 65 years of age (the Cardiovascular Health Study). Am J Cardiol. 2006; 97: 83-89 Abstract Full Text Full Text PDF PubMed Scopus (258) Google Scholar and once HF is present, LA enlargement and dysfunction forecast clinical outcomes in patients with DCM. For example, LA dimension predicted mortality and HF hospitalization after adjusting for LV ejection fraction (EF), NYHA class, and etiology in 1172 patients enrolled in the SOLVD trials 4 Quinones M.A. Greenberg B.H. Kopelen H.A. Koilpillai C. Limacher M.C. Shindler D.M. et al. Echocardiographic predictors of clinical outcome in patients with left ventricular dysfunction enrolled in the SOLVD registry and trials: significance of left ventricular hypertrophy. Studies of left ventricular dysfunction. J Am Coll Cardiol. 2000; 35: 1237-1242 Abstract Full Text Full Text PDF PubMed Scopus (212) Google Scholar and LA area was a powerful predictor of death or hospitalization from HF independent of age, NYHA class, LVEF and a restrictive filling pattern in 1157 patients from a meta-analysis of 18 HF studies. 5 Rossi R. Temporelli P.L. Quintana M. Ghio S. Hillis G.S. Klein A.L. et al. Independent relationship of left atrial size and mortality in patients with heart failure: an individual patient meta-analysis of longitudinal data (MeRGE Heart Failure). Eur J Heart Fail. 2009; 11: 929-936 Crossref PubMed Scopus (125) Google Scholar In another study of 337 patients with dilated cardiomyopathy, maximum LA volume (LAV) predicted death and transplant over a mean follow-up of 41 months, independent of atrial fibrillation (AF), LV volume, LVEF, mitral regurgitation (MR) and transmitral E/A ratio. 6 Rossi A. Cicoira M. Zanolla L. Golia G. Franceschini L. Brighetti G. et al. Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol. 2002; 40: 1425 Abstract Full Text Full Text PDF PubMed Scopus (287) Google Scholar Indexed LAV (LAVi) was also shown to be an independent predictor for cardiac events in 146 patients hospitalized for HF that were followed for a median of 448 days; in that study, a stepwise increase in the risk of cardiac events for each categorical increment of LAVi was demonstrated. 7 Tamura H. Watanabe T. Nishiyama S. Sasaki S. Arimoto T. Takahashi H. et al. Increased left atrial volume index predicts a poor prognosis in patients with heart failure. J Card Fail. 2011; 17: 210-216 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar In the Heart and Soul Study, LAVi was measured in 935 ambulatory patients with coronary disease but without atrial arrhythmia or significant mitral valve disease; LAVi > 50 mL/m2 performed as well as the LVEF in its ability to predict HF hospitalization and mortality. 8 Ristow B. Ali S. Whooley M.A. Schiller N.B. Usefulness of left atrial volume index to predict heart failure hospitalization and mortality in ambulatory patients with coronary heart disease and comparison to left ventricular ejection fraction (from the Heart and Soul Study). Am J Cardiol. 2008; 102: 70-76 Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Finally, a real-time 3-dimensional echo-determined LAV > 100 mL predicted 1-year adverse cardiovascular outcomes among patients with pre-existing severe LV dysfunction. 9 Suh I.W. Song J.M. Lee E.Y. Kang S.H. Kim M.J. Kim J.J. et al. Left atrial volume measured by real-time 3-dimensional echocardiography predicts clinical outcomes in patients with severe left ventricular dysfunction and in sinus rhythm. J Am Soc Echocardiogr. 2008; 21: 439-445 Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Thus, in view of its established predictive power for the progression of HF, the ability of LAVi to forecast the recovery of LV function in patients with new-onset DCM is not entirely surprising.

We have previously shown that prolonged high-saturated fat feeding (SAT) for 8 weeks after myocardial infarction (MI) improves ventricular function and prevents the metabolic remodeling commonly observed in heart failure. The current study was designed to delineate the interplay between markers of energy metabolism and indices of cardiac remodeling with 2 and 4 weeks of post-MI SAT in male Wistar rats. By 2 weeks, less remodeling was noted in MI-SAT evidenced by diminished chamber dilation and greater ejection fraction assessed by echocardiography and hemodynamic measures. In addition, gene expression of energy metabolism targets involved in FA uptake, oxidation, and glucose oxidation regulation was increased in MI-SAT with respect to MI alone, although no change in PDH phosphorylation was observed. The regulatory kinase, phosphoinositide 3 kinase (Pi3k), was strongly induced by 2 weeks in the MI-SAT group, although AKT protein content (a primary downstream target of PI3K that affects metabolism) was decreased by both MI and SAT alone, indicating early involvement of cellular signaling pathways in lipid-mediated cardioprotection. Our results demonstrate that cardioprotection occurs acutely with SAT following MI, with improvement in indices of both cardiac function and fatty acid oxidation, suggesting a mechanistic role for energy metabolism in the beneficial effects of high dietary fat following cardiac injury.

Objectives Evidence to support the use of pericardial drainage instead of simple pericardiocentesis for nonmalignant pericardial effusions refractory to medical therapy is based on observational studies and experts’ opinions, rather than randomized trials. The aim of the present trial is to fill this knowledge gap and to provide a stronger base of evidence to support a specific interventional treatment in this setting. Methods DRainage Or Pericardiocentesis (DROP) alone for recurrent nonmalignant, nonbacterial pericardial effusions requiring intervention is a randomized, open-label and multicenter study. The primary efficacy endpoints are the incidence of recurrent pericardial effusion, and the need for additional pericardiocentesis or cardiac surgery at 12 months. Secondary endpoints are hospital length stay, disease-related admission and overall mortality. Safety and complications rates of each intervention will be also assessed. Implications and conclusion The DROP trial will be the first multicenter randomized trial to evaluate the efficacy and safety of pericardiocentesis versus pericardiocentesis and extended pericardial drainage for recurrent nonmalignant, nonbacterial pericardial effusions refractory to medical therapy and requiring interventional treatments (ClinicalTrials.gov Identifier: NCT01665495).

Background Cardiac hypertrophy in athletes is adaptive and distinct from pathological hypertrophy. Mice that over‐express phosphoenolpyruvate carboxykinase (PEPCK‐C) in skeletal muscle are more active and live longer compared to controls. We hypothesized that PEPCK‐C mus mice would have an athletic cardiac phenotype in the absence of an imposed exercise regimen. Methods Analysis of activity level, cardiac structure with conventional (M‐mode, Doppler) and deformational (midwall strain, strain rate) echocardiographic parameters, and cardiac MRI for torsion and time to peak strain (Tpk) in PEPCK‐C mus and control mice. Results The heart rate, end diastolic dimension, LV fraction shortening and ventricular torsion were similar between groups. Measurement Unit Control (n=5) PEPCK‐C mus (n=6) Activity Distance moved cm 61999 +25.2 85830 +33.5 * Echocardiography RWT cm 0.56 +0.13 0.89 +0.16 * LVMI mg/weight 3 +0.11 5+0.11 * MPI (LV) 0.45 +0.02 0.35 +0.07 * CO cc 0.09 +0.02 0.24 +0.06 * CS % −27.4 +5.7 −49.1+3.1 * CS rate 1/s −7.7 +1.8 −17.5+1.9 * RS % +16.9 +1.2 +37.386 +5.9 * RS rate 1/s +4.6 +1.1 +7.8 +1.6 * Cardiac MRI Tpk % 60 +1.2 40 +2.1 * P‐value <0.05, RWT=relative wall thickness; LVMI=LV mass index; MPI=myocardial performance index; CO=cardiac output; CS=circumferential strain; RS=radial strain Conclusions Untrained PEPCK‐C mus mice have greater activity and their hearts have phenotypical changes characteristic of the athlete's heart, and are a novel model for non‐pathological cardiac hypertrophy that may be useful for comparison with other mice models of hypertrophy. The radial and circumferential strain measurements were distinctly different in the PEPCK‐C mus mice indicating these parameters should be considered when clinically assessing hypertrophy. Our future plan is to analyze molecular changes (VEGF, PECAM) by Western blots in PEPCK‐C mus and control mice. Grant Funding Source : N/A