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.

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.

To determine the natural history of the cardiac manifestations, determined by advanced transthoracic echocardiography (TTE), due to COVID-19 in multiethnic hospitalised patients. A prospective observational study, in a London NHS Trust, of patients admitted with COVID-19 undergoing TTE. Baseline TTE was taken during acute admission with follow-up TTE at a median of 17.6 months to assess the same left ventricular (LV), right ventricular (RV) and pulmonary pressure parameters with additional 3D and strain measures. There were a total of 117 patients with admission and follow-up TTE. LV parameters were largely unchanged at follow-up except E/A ratio decreasing from 0.98 to 0.85. LV global longitudinal strain measures detected subclinical LV impairment in 36

We present the case of a 52-year-old male with severe primary mitral regurgitation, with biventricular dilatation and systolic impairment. Pre-operative exercise stress echocardiography revealed absence of left and right ventricular contractile reserve suggestive of increased surgical risk possibly requiring postoperative mechanical circulatory support. In the immediate postoperative period, the transesophageal echocardiogram revealed severe left ventricular systolic impairment with very low cardiac output, resulting in significant challenges in weaning the patient off cardiopulmonary bypass. Left ventricular function gradually improved with judicious use of intravenous fluids and inotropic support. Our case highlights the importance of stress echocardiography in the risk stratification and periprocedural planning of patients undergoing cardiac surgery for severe mitral regurgitation.

Myocardial perfusion quantification using contrast-enhanced ultrasound offers a bedside non-ionizing alternative to nuclear imaging modalities. However, its clinical adoption is hindered by time-consuming manual labelling. Automated segmentation has proved challenging due to a paucity of in-domain training data. Adapting strategies currently used to optimise large language models for large datasets, we apply neural scaling laws to predict network performance for myocardial segmentation. We extrapolate performance on subsets of the data to determine optimal network size on the CAMUS echocardiography dataset and a 25-patient contrast-enhanced ultrasound (CEUS) dataset. Finally, we validate the clinical utility of our models by comparing the final myocardial perfusion parameters with those obtained by a senior cardiologist. Extrapolation based on the scaling law is predictive of test loss at the full dataset size, allowing us to select two networks that obtained state-of-the-art performance on CAMUS with a 240-fold reduction in parameter count. We observe the gradient of the scaling law transfers from CAMUS to the CEUS dataset with a bias in the predicted losses. The automatically segmented masks perform equivalently to a senior cardiologist in myocardial perfusion quantification. These results establish neural scaling laws as a practical tool for data-driven compute-optimal model design for small imaging datasets.

The primary analysis of the SELECT randomized clinical trial suggests that semaglutide reduced the rates of cardiovascular (CV) death, myocardial infarction, and stroke in patients with established CV disease (CVD) and overweight or obesity without diabetes. However, the effect of semaglutide on hospitalizations in this population remains unknown. To determine the impact of semaglutide on total hospital admissions and duration of hospital stay. The SELECT trial included patients aged 45 years or older with established CVD and a body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of 27 or higher without diabetes at 804 clinical settings across North America, South America, Europe, Asia, Africa, and Australia. Patients were randomized from October 2018 to March 2021. This prespecified exploratory analysis was conducted from February 2024 to September 2025. Once-weekly subcutaneous semaglutide, 2.4 mg, or placebo. The total number of hospital admissions and days in hospital between the semaglutide and placebo groups. A total of 17 604 patients (median [IQR] age, 61.0 [55.0-68.0] years; 4872 female patients [27.7%]; median [IQR] BMI, 32.1 [29.7-35.7]) were followed up for a median (IQR) period of 41.8 (33.0-47.0) months. There were 11 287 hospital admissions. The number of total hospitalizations was lower in the semaglutide group vs placebo for any indication (18.3 vs 20.4 admissions per 100 patient-years; mean ratio [MR], 0.90; 95% CI, 0.85-0.95; P < .001) and for serious adverse events (15.2 vs 17.1 admissions per 100 patient-years; MR, 0.89; 95% CI, 0.84-0.94; P < .001). The number of days hospitalized for any indication per 100 patient-years was lower in the semaglutide group vs placebo (157.2 vs 176.2 days; rate ratio [RR], 0.89; 95% CI, 0.82-0.98; P = .01), as well as hospitalizations for serious adverse events (137.6 vs 153.9 days; RR, 0.89; 95% CI, 0.81-0.98; P = .02). No heterogeneity was observed for the reduction of hospital admissions with semaglutide in selected subgroups, including BMI, age, and sex. In this prespecified exploratory analysis of the SELECT randomized clinical trial, the trial cohort had a high rate of hospital admissions. Treatment with once-weekly semaglutide was associated with significant reductions in hospital admissions and overall time spent in hospital, extending its benefits beyond CV risk reduction. ClinicalTrials.gov Identifier: NCT03574597

Background:Two-dimensional echocardiography is the most widely used imaging modality for immediate diagnosis, due to its easy access and cost-effectiveness. International guidelines recommend four standard views to perform a comprehensive minimum dataset for every adult patient, namely left parasternal, apical, subcostal, and suprasternal views. Case summary:In this case series, we revisit the right parasternal view (RPV). Although it is infrequently used in routine clinical practice, it provides valuable complementary information, particularly when abnormalities are found on the minimum dataset or when measurement results are inconsistent. Including this view in the imaging protocol adds only a few extra minutes but can yield important additional diagnostic information. Discussion:Presented are four cases in which the complementary use of RPV provided decisive diagnostic information that was either missed or underestimated by standard echocardiographic windows and influenced clinical management, re-emphasizing the value of adding this view during a routine examination.

AIMS:The objective of our study was to establish the prevalence of ischemia during exercise stress echocardiography (ESE) in patients with anomalous aortic origin of coronary arteries (AAOCA). METHODS AND RESULTS:A cohort of 46 patients with AAOCA was retrospectively included in this study. Treadmill/bike exercise stress echo tests for ischemia assessment were performed and analyzed according to ESC guidelines. Computed tomography coronary angiography (CTCA), cardiac magnetic resonance, myocardial perfusion scintigraphy and invasive angiography with intravascular ultrasound if needed were used for coronary artery (CA) morphology and myocardial perfusion assessment. Most patients (70%) were overall symptomatic at rest, 57% reported chest pain and 2% had cardiac arrest before the ESE. By contrast, only 2% of patients reported chest pain during ESE. CTCA revealed that 70% of patients had an inter-arterial course, 17% were found to have an intramural course and 24% had a slit-like ostium of their anomalous CA. Other high-risk features were less frequent findings. All myocardial perfusion studies were negative and only one patient with AAOCA developed ischemia during ESE. Following investigations, four patients were eligible for surgical interventions and were operated on while the remaining patients were followed up for a median of 3 years with no adverse cardiovascular events. CONCLUSIONS:Incidence of ischemia on exercise stress echo is extremely low among middle-aged patients with AAOCA despite symptoms at rest and malignant anatomical features. A good short-term outcome in unoperated AAOCA patients following negative exercise stress echocardiography has been shown.

Background: Ultrafast ultrasound or High Frame Rate (HFR) myocardial contrast echocardiography (MCE) due to its high temporal resolution (>1000 frames/sec) can reduce noise and improve perfusion assessment. We hypothesised that quantitative HFR MCE is superior to quantitative conventional MCE in evaluating patients with obstructive coronary artery disease (OCAD). Methods: 25 consecutive eligible patients consisting of 20 patients (pts) with high pre-test probability (PTP) and 5 with low PTP for OCAD underwent rest and stress perfusion imaging with conventional and HFR MCE during intravenous infusion of a commercially used microbubbles at rest and following vasodilator stress. All patients with high PTP for OCAD also underwent invasive coronary angiography. Quantitative analysis of myocardial perfusion at rest and stress was performed using the time-intensity curve with both conventional and HFR MCE and were correlated with coronary angiography. Myocardial blood flow reserve (MBFR) was derived (MBFR<2.0 was considered reduced). Results: Of the 20 pts with high PTP, 18 pts demonstrated 27 vascular territories with OCAD on coronary angiography. Of these 27 vascular territories with OCAD, HFR MCE identified 25 (93%) vascular territories with reduced MBFR compared to 22 (81%) by conventional MCE (p 0.22). Of the 12 normal vascular territories in 4 pts with low PTP, HFR MCE identified 7 (58%) vascular territories as normal vs 5 (42%) by conventional MCE (p 0.41). Accuracy for the detection of OCAD by HFR vs conventional MCE were 32/39 (83%) vs 27/39 (69%) respectively (p 0.18). However, the number of segments with low MBFR detected by HFR MCE in pts with OCAD was significantly higher 92 (73%) compared to 83 (66%) by conventional MCE (p 0.02). Furthermore, hyperaemic MBF was significantly lower with HFR vs conventional MCE (0.8 +/- 0.1 SD vs 1.6 +/- 0.3 SD respectively, p 0.03). Interobserver variability by two different physicians from randomly selected 7 patients involving 21 vascular territories (13 OCAD and 8 territories in low PTP pts) demonstrated concordance of 94%, and 100% for HFR vs conventional MCE respectively for the correct identification of normal and abnormal MBFR. Conclusion: In the first study in humans with suspected OCAD, quantitative Ultrafast MCE was similar to conventional MCE for the detection of OCAD but was superior in identifying the extent and intensity of inducible myocardial ischemia which has both therapeutic and prognostic implications.

Aims Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported. Methods and results Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73-4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease. Conclusion In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.

Contrast enhanced ultrasound (CEUS) offers a safe, reliable imaging option to establish a clinical diagnosis across a variety of multidisciplinary settings. This Expert Consensus Statement serves to outline expert opinion on what constitutes appropriate supervision and the essential components of safe CEUS practice. The purpose of this document is to empower institutions to allow sonographers, along with other trained medical professionals, to administer UCAs at the point of care, consistent with the updated scope of practice documentation and within the broad parameters of an individual’s training and licensure, while subject to appropriate supervision and meeting or exceeding minimum safety standards. This guidance was developed by the International Contrast Ultrasound Society and endorsed by the following organizations that represent ultrasound professionals: the British Society of Echocardiography, the Canadian Society of Echocardiography, the Society of Diagnostic Medical Sonography, the Society for Pediatric Radiology, the World Federation of Ultrasound in Medicine and Biology, the Brazilian College of Radiology, the Joint Review Committee for Diagnostic Medical Sonography, the Chinese Ultrasound Doctors Association, and the American Society of Neuroimaging. Additionally, this guidance document was affirmed or supported by the American Society of Echocardiography, the Association for Medical Ultrasound, and the Society for Vascular Ultrasound.

Abstract Background Guidelines advocate the use of dobutamine echocardiography (DSE) in low-gradient aortic stenosis (LGAS: AVA<1cm² with AVMG<40mmHg) with reduced left ventricular ejection fraction (LVEF <50%) for determining AS severity and deciding on subsequent patient management. However, a significant proportion of patients have inconclusive DSE (indeterminate AS). Purpose We aimed to assess the impact of DSE on the management of patients with LGAS and reduced LVEF as well as the application of transaortic flow-based criteria for severe AS to improve the diagnostic yield of DSE. Finally, we aimed to review the impact of aortic valve intervention in those with indeterminate AS. Methods Accordingly, a retrospective analysis of 287 patients with LGAS and reduced LVEF (<50%) who underwent DSE was performed. We used the conventional criteria for classification of AS severity following DSE: severe AS when AVA <1cm² with AVMG ≥40mmHg, moderate AS when AVA ≥1cm², and indeterminate AS when AVA <1cm² and AVMG <40mmHg during stress. Furthermore, we assessed the proposed new criteria for AS classification: AVA <1cm² at normalised FR ≥210ml/s and projected AVA <1cm² at FR of 250ml/s. We also assessed the impact of afterload on the different AS groups by means of valvular resistance (valve disease related afterload) and arterial impedance (vascular disease related afterload). Results Following DSE 84 (29%) patients had severe AS, 81 (28%) moderate AS, and 122 (43%) indeterminate AS. Over the median follow-up of 12.0 (IQR= 5-33) months more patients with severe AS (73%) underwent aortic valve intervention compared with moderate (40%) and indeterminate AS (44%) (p< 0.001). In terms of afterload, the valvular resistance was significantly higher in patients with severe AS compared to indeterminate AS (p<0.001), but arterial impedance was higher in indeterminate AS amongst all 3 groups (p=0.02). Use of the proposed combined criteria for severe AS (AVA <1cm² at FR ≥210ml/s or projected AVA) in the indeterminate AS group improved the proportion of diagnostic tests from 57% to 90%, increased detection of severe AS from 29% to 61%, and reduced indeterminate AS to 9%. Aortic valve intervention was beneficial in the reclassified severe AS patients (HR 0.50, 95%CI 0.27-0.92, p=0.03) (Fig.1A), but not in the remaining indeterminate AS patients (HR 0.77, 95%CI 0.22-2.75, p=0.69) (Fig.1B). The benefit of aortic valve intervention was larger in the conventionally diagnosed severe AS patients compared to the reclassified severe AS patients (HR 2.88, 95%CI 1.34-6.21, p=0.007) (Fig.1C). Conclusions Clinicians managed LGAS patients according to DSE-determined AS severity. Application of the proposed combined criteria for severe AS reduced the number of non-diagnostic DSE and increased the detection of severe AS. In the reclassified severe AS patients aortic valve intervention can be beneficial, but not in those who remained indeterminate AS. Figure 1

Ultrasound enhancing agents (UEAs, formerly called contrast agents) for assessments of the left heart have improved the applicability of echocardiography and the accuracy of echocardiographic measurements. UEAs have been recommended for several diagnostic echocardiographic procedures by national and supernational agencies. The increased use of UEAs during the last years provided more evidence and experience in clinical practice data which is helpful for optimizing the UEA procedures and which will be useful for both newcomers to UEA in echocardiography and sonographers/physicians with experience in echocardiography with UEAs. In two parts, this review focuses on the “how to do” for the approved UEA applications. This is part 1, covering the available UEAs and providing specific guidance on the assessment of global and regional LV function. Part 2 covers the imaging of myocardial disease and masses as well as myocardial perfusion. Recommendations include the application of UEAs in two-dimensional echocardiography as there is limited data on three-dimensional echocardiography. A step-by-step approach is proposed for each of the procedures as well as guidance on how to interpret recordings and how to report them.

BACKGROUND:This study examined stress echocardiography in relation to coronary artery anatomy and outcome in subjects randomized in the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. METHODS:Of 5,179 patients randomized to initial invasive or conservative strategy, stress echocardiography was performed in 1,079. Coronary computed tomographic angiogram (CCTA) excluded left main disease and quantified coronary lesions. Degree of ischemia was defined by number of segments with stress-induced wall motion abnormalities (mild < 3, moderate = 3, and severe > 3). Transient ischemic dilation was defined as a 10% increase in stress left ventricular end-systolic volume. Primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS:On CCTA, 607/715 (84%) with CCTA evaluable for ≥70% lesion had 1 such lesion. Features associated with coronary lesions ≥70% were number of ischemic/infarcted segments, 3 or more ischemic segments in the anterior territory, and inability to augment left ventricular ejection fraction 10 percentage points. Transient ischemic dilation, present in 28.5% of cases, was significantly associated with severity of ischemia. For every 0.10 increase in peak wall motion score index, there was a 12% increased risk of cardiovascular death or myocardial infarction (adjusted hazard ratio = 1.12; 95% CI, 1.04, 1.21; P = .003). CONCLUSION:In patients with chronic coronary disease and moderate or severe myocardial ischemia receiving contemporary therapies, stress echocardiography identified subjects with significant coronary artery disease and wall motion score index provided prognostic value.

Ultrasound enhancing agents (UEAs, formerly called contrast agents) have enhanced echocardiographic diagnostics of myocardial disease and masses as well as myocardial perfusion abnormalities. This review provides up-to-date guidance on the procedures and interpretations according to current recommendations of imaging societies and considering the results of recent major studies. For the different indications, a standardized approach has been created including technical aspects, pre-assessment and primary scan planes, contrast-enhanced ultrasound (CEUS) procedure, interpretation and reporting. In a previous publication (part 1) the UEAs, imaging methods, preparation of the patients and assessment of global and regional LV function with UEAs were included. The two parts represent a comprehensive state-of-the-art compendium on how to perform CEUS examinations in clinical echocardiography and provide advice on education, qualification and quality control.

Stress echocardiography is a key imaging modality for assessing coronary artery disease in the UK. Traditionally, stress echo services were led by consultant cardiologists, but evolving workforce models have increased the involvement of cardiac physiologists and scientists. This study, as part of the National Review of Stress Echocardiography Practice (BSE N-STEP), aimed to evaluate current stress echo workforce structures and test outcomes across a group of UK hospitals to inform future workforce planning. Data were analysed from 8506 stress echocardiograms, conducted between September 2020 and June 2023 across 34 UK hospitals. Based on the supervising workforce, stress echocardiograms were allocated into either a doctor-led (DL) or cardiac physiologist/scientist and nurse-led (CNL) model. 56.9