Normalized Echocardiographic Values From Guideline-Directed Dedicated Views for Cardiac Dimensions and Left Ventricular Function

The power of the left atrioventricular coupling index in cardiovascular disease

The left atrioventricular coupling index (LACI) has emerged as a novel and transformative biomarker in cardiovascular research, addressing long-standing limitations in traditional cardiac function assessments. By quantifying the ratio of left atrial to left ventricular end-diastolic volumes, LACI offers unprecedented prognostic insights into a wide range of cardiovascular diseases, including atrial fibrillation, heart failure, and myocardial infarction, as well as other conditions such as hypertension and cardiomyopathies. Recent evidence highlights its unique ability to integrate atrial and ventricular dynamics, offering a more comprehensive perspective on cardiac health and disease progression. This review synthesizes the latest advancements in LACI research, elucidates its underlying pathophysiological mechanisms, and explores its expanding clinical applications as a pivotal tool for risk stratification, precision diagnostics, and personalized therapy in cardiovascular medicine.

Sex-Specific Differences in Echocardiographic Parameters of Risk Stratification in Pulmonary Arterial Hypertension

BACKGROUND

In healthy subjects, sex differences in right heart function have been detected for various echocardiographic parameters. The objective of this study was to investigate sex differences in echocardiographic European Society of Cardiology (ESC)/European Respiratory Society (ERS) risk stratification parameters and their impact on survival estimation in patients with pulmonary arterial hypertension (PAH).

METHODS

In this retrospective, cross-sectional study with a mean follow-up time of 3.2 ± 2.65 years (median, 2.78 years), clinical parameters including right atrial (RA) area, right ventricular area, and tricuspid annular plane systolic excursion (TAPSE) divided by systolic pulmonary artery pressure (sPAP) were assessed. Thresholds of ESC/ERS risk stratification were compared using multivariable Cox regression analysis.

RESULTS

Of 748 patients with PAH (mean age, 65 ± 15 years; 63% women), men had significantly larger right heart size than women (RA area 21.76 ± 7.64 vs 17.65 ± 6.82 cm2, P < .001; right ventricular area 24.02 ± 7.15 cm2 vs 18.41 ± 5.75 cm2, P < .001). This difference was consistent throughout all World Health Organization functional classes and cardiac index risk groups, except for the RA area in the cardiac index high-risk group and World Health Organization functional class IV. On multivariable analysis, indexed values showed more pronounced differences for age-adjusted survival analysis compared with ESC/ERS risk stratification thresholds. TAPSE/sPAP showed no significant sex differences, which makes this parameter a robust prognostic predictor.

CONCLUSIONS

This is the first study focusing on sex differences in right heart size obtained by echocardiography in patients with PAH. For risk stratification indexing RA area to body surface area could be more reflective of body composition. In contrast, TAPSE/sPAP values were not sex dependent and were a robust prognostic factor in patients with PAH.

Aberration correction-impact on image quality and chamber quantification in transthoracic echocardiography

Aims

To improve image quality (IQ) in echocardiography, an aberration correction (AC) algorithm has recently been implemented in commercial scanners. We aimed to study (i) the correlation of a subjective IQ-score and an objective IQ-metric [global image coherence (GIC)], (ii) if AC improved IQ; (iii) if AC affected average values and interobserver agreement of left ventricular (LV) size, LV longitudinal strain, and left atrial (LA) volume.

Methods and results

From 50 adult patients, where 45 (90%) had cardiovascular disease, unprocessed image data (channel data) were acquired from six standard transthoracic views. The data were processed with and without AC, resulting in 300 pairs of cine-loops. The cine-loops were randomly presented one-by-one to two blinded raters experienced in echocardiography. Both raters scored IQ subjectively from 1 (poor) to 4 (very good) and quantified LV dimensions, volumes and longitudinal strain, and LA volume. IQ-score correlated with GIC, Spearman rho 0.72, P < 0.001. AC improved median IQ-score from 2.5 to 3.0 (Wilcoxon signed rank: P < 0.001). The differences in average values of LV size, LV longitudinal strain, or LA volume with and without AC were not statistically significant and numerically minimal. Measured by intraclass correlation, interobserver agreement of these values was not significantly affected by AC.

Conclusion

Image quality-score strongly correlated with GIC. Aberration correction improved IQ. However, AC did not lead to statistically significant changes in average values or interobserver agreement of LV size, LV longitudinal strain or LA volume quantification. Likely, the major benefit of AC is enhanced visualization of anatomical details.

Association between allostatic load and cardiac structural and functional abnormalities in young adults with serious mental disorders

OBJECTIVE

Allostatic load refers to the pathophysiological consequences of uncompensated adaptation to chronic stress. Few studies have investigated the effect of allostatic load on cardiac health in patients with serious mental disorders (SMDs), a population at high risk of cardiac mortality. Herein we evaluated associations between allostatic load and cardiac structure and function in young adults with SMDs.

METHOD

A total of 106 participants aged younger than 45 years underwent echocardiographic study, blood biochemistry examination, and blood cell count analysis. Echocardiographic imaging was conducted in accordance with recommendations of the American Society of Echocardiography and European Association of Cardiovascular Imaging. Allostatic load index was calculated using 15 measures representing cardiovascular, metabolic, and inflammatory or oxidative stress markers.

RESULTS

The SMD group exhibited a significantly higher allostatic load index than did control (Cohen's d = 0.59). Additionally, they exhibited a greater left ventricular relative wall thickness (LVRWT, Cohen's d = 0.39) and a less favorable mitral valve E/A ratio (Cohen's d = 0.31), left ventricular ejection fraction (Cohen's d = 0.51), and global longitudinal strain (Cohen's d = 0.71). After demographic and clinical characteristics were adjusted for, multiple linear regression revealed that allostatic load index was positively associated with LVRWT (β = 0.255) and negatively associated with mitral valve E/A ratio (β = -0.247) in the SMD group.

CONCLUSIONS

This is the first study to suggest that allostatic load may play a critical role in accelerated adverse cardiac remodeling among young patients with SMDs. Future studies should elucidate the underlying mechanisms.

Comparison of the Effectiveness of Body Surface Area Estimation Formulas in Predicting the Risk of Death in Patients with Heart Failure

Background/Objectives: Body surface area is one of the most important anthropometric parameters in medicine. The study's primary objective is to compare the consistency of the BSA estimation results through applying available formulas. Other objectives include determining the ability of these formulas to discriminate between death and survival in patients, comparing the formulas' diagnostic features, and investigating whether the risk associated with a low BSA is independent of BMI. Methods: This study included 1029 patients (median age, 54 years; female, 13.7%; NYHA I/II/III/IV, 6.3%/36.5%/47.7%/9.5%) diagnosed with heart failure. For each patient, BSA was calculated using 25 formulas. Over the 3-year observation period, 31.2% of the patients died. Results: The average BSA value of the optimal discrimination thresholds was 1.79 m2 ± 0.084 m2 and the BSA difference between the estimators with the lowest (BSAMeeh1879) and the highest (BSANwoye1989) optimal discrimination thresholds was 0.42 m2. The lowest mortality rate was 35.2% and occurred in the subgroup of individuals with BSA values below the optimal discrimination threshold using the BSASchlich2010 estimator. The highest mortality was predicted when the estimator BSAMeeh1879 or BSALivingston&Lee2001 was used. Conclusions: Our study showed a relatively good concordance of 25 BSA estimators in BSA assessment in patients, without extremes of weight or height being known to disrupt it. All BSA estimators presented a significant, although weak, ability to discriminate death from survival at 3-year follow-up; however, BSA is not a very good predictor of HF mortality at 3 years. The higher risk of death in smaller patients, as shown by BSA, was independent of BMI in all but two BSA estimators.

Reference intervals of circulating secretoneurin concentrations determined in a large cohort of community dwellers: the HUNT study

OBJECTIVES

Secretoneurin (SN) is a novel cardiac biomarker that associates with the risk of mortality and dysfunctional cardiomyocyte Ca2+ handling in heart failure patients. Reference intervals for SN are unknown.

METHODS

SN was measured with a CE-marked ELISA in healthy community dwellers from the fourth wave of the Trøndelag Health Study (HUNT4) conducted in 2017-2019. The common, sex and age specific 90th, 95th, 97.5th and 99th percentiles were calculated using the non-parametric method and outlier exclusion according to the Reed test. The applicability of sex and age specific reference intervals were investigated using Harris and Boyd test. We also estimated the percentiles in a subset with normal findings on echocardiographic screening.

RESULTS

The total cohort included 887 persons (56.4 % women). After echocardiographic screening 122 persons were excluded, leaving a total of 765 persons (57.8 % women). The 97.5th percentile (95 % CI in brackets) of SN was 59.7 (57.5-62.1) pmol/L in the total population and 58.6 (57.1-62.1) pmol/L after echocardiography screening. In general, slightly higher percentiles were found in women and elderly participants, but less than 4 % in these subgroups had concentrations deviating from the common 97.5th percentile. Low BMI or eGFR was also associated with higher concentrations of SN.

CONCLUSIONS

Upper reference limits for SN were similar amongst healthy adult community dwellers regardless of prescreening including cardiac echocardiography or not. Women and elderly showed higher concentrations of SN, but the differences were not sufficiently large to justify age and sex stratified upper reference limits.

Lone Giant Atrium as a Variant of Atrial Cardiomyopathy: A Cardiovascular Magnetic Resonance Imaging Case Series

Advances in cardiovascular imaging have expanded the scope and precision of rare diagnoses. Handling a patient with a giant left atrium, we focused on the existence and associated factors of "lone giant (left or right) atria" in our clinical setting. The aim of the current study was to establish reasonable cut-off values for the diagnosis of "giant atrium". Our analysis utilised echocardiography and cardiovascular magnetic resonance (CMR) imaging databases, with the original data re-assessed to ensure consistency and comparability. Four patients met the search criteria, with two cases requiring CMR to confirm the diagnosis of "giant atrium", correcting the initial echocardiographic assessment. Both echocardiography and CMR excel in the assessment of atrial anatomy, although the superior image quality and multiplanar capabilities of CMR support its preference. In assessing the atrial size, the use of 3D volumetric measurements should replace traditional biplane methods due to the complex anatomy of the atrium. We propose the use of an indexed volume threshold (>120 mL/m2) rather than simple diameter measurements for the diagnosis of "giant atria". Structural atrial abnormalities appear to correlate with an increased risk of atrial arrhythmias, while potential serious complications such as thromboembolism or compression symptoms require further observation in larger patient cohorts to establish definitive risks.

Current and Clinically Relevant Echocardiographic Parameters to Analyze Left Atrial Function

The evaluation of the left atrial (LA) size using the LA volume index (LAVI) is clinically relevant due to its prognostic significance in various conditions. Nonetheless, adding a LA function assessment to the LAVI provides further clinical and prognostic information in different cardiovascular (CV) diseases. The assessment of LA function by echocardiography primarily includes volumetric measurements (LA ejection fraction [LAEF]), tissue Doppler imaging (TDI) (mitral annular late diastolic velocity [a']), and speckle-tracking methods, such as LA longitudinal reservoir strain (LA strain). This review analyzes and discusses the current medical evidence and potential clinical usefulness of these different methods to analyze LA function.

Normative Values of Echocardiographic Chamber Size and Function in Older Healthy Adults: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Echocardiographic (2-dimensional echocardiography) thresholds indicating disease or impaired functional status compared with normal physiological aging in individuals aged ≥65 years are not clearly defined. In the present study, we sought to establish standard values for 2-dimensional echocardiography parameters related to chamber size and function in older adults without cardiopulmonary or cardiometabolic conditions.

METHODS

In this cross-sectional study of 3032 individuals who underwent 2-dimensional echocardiography at exam 6 in the MESA (Multi-Ethnic Study of Atherosclerosis), 608 participants fulfilled our inclusion criteria of healthy aging, with normative values defined as the mean ± 1.96 standard deviation and compared across sex and race and ethnicity. Functional status measures included NT-proBNP (N-terminal pro-B-type natriuretic peptide), 6-minute walk distance, and Kansas City Cardiomyopathy Questionnaire. Prognostic performance using MESA cutoffs was compared with established guideline cutoffs using time-to-event analysis.

RESULTS

The normative aging cohort (69.5±7.0 years, 46.2% male, 47.5% White) had lower NT-proBNP, higher 6-minute walk distance, and higher (better) Kansas City Cardiomyopathy Questionnaire summary values. Women had significantly smaller chamber sizes and better biventricular systolic function. White participants had the largest chamber dimensions, whereas Chinese participants had the smallest, even after adjustment for body size. Current guidelines identified 81.6% of healthy older adults in MESA as having cardiac abnormalities.

CONCLUSIONS

Among a large, diverse group of healthy older adults, we found significant differences in cardiac structure and function by sex and race/ethnicity, which may signal sex-specific cardiac remodeling with advancing age. It is crucial for existing guidelines to consider the observed and clinically significant differences in cardiac structure and function associated with healthy aging. Our study highlights that existing guidelines, which grade abnormalities in echocardiographic cardiac chamber size and function based on younger individuals, may not adequately address the anticipated changes associated with normal aging.

Automatic measurements of left ventricular volumes and ejection fraction by artificial intelligence: clinical validation in real time and large databases

AIMS

Echocardiography is a cornerstone in cardiac imaging, and left ventricular (LV) ejection fraction (EF) is a key parameter for patient management. Recent advances in artificial intelligence (AI) have enabled fully automatic measurements of LV volumes and EF both during scanning and in stored recordings. The aim of this study was to evaluate the impact of implementing AI measurements on acquisition and processing time and test-retest reproducibility compared with standard clinical workflow, as well as to study the agreement with reference in large internal and external databases.

METHODS AND RESULTS

Fully automatic measurements of LV volumes and EF by a novel AI software were compared with manual measurements in the following clinical scenarios: (i) in real time use during scanning of 50 consecutive patients, (ii) in 40 subjects with repeated echocardiographic examinations and manual measurements by 4 readers, and (iii) in large internal and external research databases of 1881 and 849 subjects, respectively. Real-time AI measurements significantly reduced the total acquisition and processing time by 77% (median 5.3 min, P < 0.001) compared with standard clinical workflow. Test-retest reproducibility of AI measurements was superior in inter-observer scenarios and non-inferior in intra-observer scenarios. AI measurements showed good agreement with reference measurements both in real time and in large research databases.

CONCLUSION

The software reduced the time taken to perform and volumetrically analyse routine echocardiograms without a decrease in accuracy compared with experts.

Mechanical Wave Velocities in Left Ventricular Walls in Healthy Subjects and Patients With Aortic Stenosis

BACKGROUND

Mechanical wave velocity (MWV) measurement is a promising method for evaluating myocardial stiffness, because these velocities are higher in patients with myocardial disease.

OBJECTIVES

Using high frame rate echocardiography and a novel method for detection of myocardial mechanical waves, this study aimed to estimate the MWVs for different left ventricular walls and events in healthy subjects and patients with aortic stenosis (AS). Feasibility and reproducibility were evaluated.

METHODS

This study included 63 healthy subjects and 13 patients with severe AS. All participants underwent echocardiographic examination including 2-dimensional high frame rate recordings using a clinical scanner. Cardiac magnetic resonance was performed in 42 subjects. The authors estimated the MWVs at atrial kick and aortic valve closure in different left ventricular walls using the clutter filter wave imaging method.

RESULTS

Mechanical wave imaging in healthy subjects demonstrated the highest feasibility for the atrial kick wave reaching >93% for all 4 examined left ventricular walls. The MWVs were higher for the inferolateral and anterolateral walls (2.2 and 2.6 m/s) compared with inferoseptal and anteroseptal walls (1.3 and 1.6 m/s) (P < 0.05) among healthy subjects. The septal MWVs at aortic valve closure were significantly higher for patients with severe AS than for healthy subjects.

CONCLUSIONS

MWV estimation during atrial kick is feasible and demonstrates higher velocities in the lateral walls, compared with septal walls. The authors propose indicators for quality assessment of the mechanical wave slope as an aid for achieving consistent measurements. The discrimination between healthy subjects and patients with AS was best for the aortic valve closure mechanical waves. (Ultrasonic Markers for Myocardial Fibrosis and Prognosis in Aortic Stenosis; NCT03422770).

Cardiovascular imaging research and innovation in 2023

In 2023, cardiovascular imaging has made significant advancements, in terms of technology, pathophysiology, and clinical application. In this review, the most recent research findings in the field of cardiovascular imaging are discussed. Artificial intelligence and large population cohorts, together with several technical improvements, have had a crucial impact on the technological advancements of echocardiography, cardiovascular magnetic resonance, computed tomography (CT), and nuclear medicine. In the field of ischaemic heart disease, it has been demonstrated that appropriate non-invasive imaging strategies improve patients' management and reduce invasive procedures and the need for additional testing at follow-up. Moreover, improvements in plaque characterization with CT are an expanding field of research with relevant implications for the prediction of disease severity, evolution, and response to treatment. In the field of valvular heart disease, imaging techniques have advanced alongside improvements in transcatheter treatment for aortic stenosis, mitral, and tricuspid regurgitation. Finally, in the field of heart failure and cardiomyopathies, cardiovascular imaging has reinforced its crucial role in early diagnosis and risk evaluation, showcasing advanced techniques that outperform traditional methods in predicting adverse outcomes.

Echocardiographic Reference Ranges of Global Longitudinal Strain for All Cardiac Chambers Using Guideline-Directed Dedicated Views

BACKGROUND

Myocardial deformation by echocardiographic strain imaging is a key measurement in cardiology, providing valuable diagnostic and prognostic information. Reference ranges for strain should be established from large healthy populations with minimal methodologic biases and variability.

OBJECTIVES

The aim of this study was to establish echocardiographic reference ranges, including lower normal limits of global strains for all 4 cardiac chambers, by guideline-directed dedicated views from a large healthy population and to evaluate the influence of subject-specific characteristics on strain.

METHODS

In total, 1,329 healthy participants from HUNT4Echo, the echocardiographic substudy of the 4th wave of the Trøndelag Health Study, were included. Echocardiographic recordings specific for each chamber were optimized according to current recommendations. Two experienced sonographers recorded all echocardiograms using GE HealthCare Vivid E95 scanners. Analyses were performed by experts using GE HealthCare EchoPAC.

RESULTS

The reference ranges for left ventricular (LV) global longitudinal strain and right ventricular free-wall strain were -24% to -16% and -35% to -17%, respectively. Correspondingly, left atrial (LA) and right atrial (RA) reservoir strains were 17% to 49% and 17% to 59%. All strains showed lower absolute values with higher age, except for LA and RA contractile strains, which were higher. The feasibility for strain was overall good (LV 96%, right ventricular 83%, LA 94%, and RA 87%). All chamber-specific strains were associated with age, and LV strain was associated with sex.

CONCLUSIONS

Reference ranges of strain for all cardiac chambers were established based on guideline-directed chamber-specific recordings. Age and sex were the most important factors influencing reference ranges and should be considered when using strain echocardiography.

Sex-Related Differences in the Prevalence of Classical, Non-Classical Risk Factors and Management of the Chronic Coronary Syndrome

(1) Background: Coronary artery disease (CAD) remains the leading cause of death in both sexes. The male sex is considered a classical atherosclerosis risk factor, whereas females should be protected by hormonal effects until menopause. Although there are known differences in the development, type, and prognosis of chronic coronary syndrome (CCS) between both sexes, there are no differences in approach in the guidelines. (2) Methods: The sex-related differences in CAD risk factors, treatment, echocardiographic, and angiographic results were assessed among 3291 patients with CCS. (3) Results: Women were older and had a higher prevalence of hypertension, dyslipidaemia, and diabetes mellitus than men. Women were more often treated conservatively than men. There was no difference in the use of beta-blockers and statins among the sexes. The LDL cholesterol goal was less frequently reached by women. Women were treated less often with aspirin than men, but they were treated more often with angiotensin receptor blockers than men. The left ventricle ejection fraction was higher among females. The number of obstructed vessels was higher in men. (4) Conclusions: Women may be more exposed to the risk factors of CAD than men. Men are diagnosed with CAD earlier, and their prevention and therapy are more efficient.

Current national availability of advanced echocardiography imaging: real world data from an Italian Society of Echocardiography and Cardiovascular Imaging survey

Aims

Advanced echocardiographic imaging (AEI) techniques, such as three-dimensional (3D) and multi-chamber speckle-tracking deformation imaging (strain) analysis, have been shown to be more accurate in assessing heart chamber geometry and function when compared with conventional echocardiography providing additional prognostic value. However, incorporating AEI alongside standard examinations may be heterogeneous between echo laboratories (echo labs). Thus, our goal was to gain a better understanding of the many AEI modalities that are available and employed in Italy.

Methods and results

The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey over a month (November 2022) to describe the use of AEI in Italy. Data were retrieved via an electronic survey based on a structured questionnaire uploaded on the SIECVI website. Data obtained from 173 echo labs were divided into 3 groups, according to the numbers of echocardiograms performed: <250 exams (low-volume activity, 53 centres), between 251 and 550 exams (moderate-volume activity, 62 centres), and ≥550 exams (high-volume activity, 58 centres). Transthoracic echocardiography (TTE) 3D was in use in 75% of centres with a consistent difference between low (55%), medium (71%), and high activity volume (85%) (P = 0.002), while 3D transoesophageal echocardiography (TEE) was in use in 84% of centres, reaching the 95% in high activity volume echo labs (P = 0.006). In centres with available 3D TTE, it was used for the left ventricle (LV) analysis in 67%, for the right ventricle (RV) in 45%, and for the left atrium (LA) in 40%, showing greater use in high-volume centres compared with low- and medium-volume centres (all P < 0.04). Strain analysis was utilized in most echo labs (80%), with a trend towards greater use in high-volume centres than low- and medium-volume centres (77%, 74%, and 90%, respectively; P = 0.08). In centres with available strain analysis, it was mainly employed for the LV (80%) and much less frequently for the RV and LA (49% and 48%, respectively).

Conclusion

In Italy, the AEI modalities are more frequently available in centres with high-volume activity but employed only in a few applications, being more frequent in analysing the LV compared with the RV and LA. Therefore, the echocardiography community and SIECVI should promote uniformity and effective training across the Italian centres. Meanwhile, collaborations across centres with various resources and expertise should be encouraged to use the benefits of the AEI.

Real-time guidance by deep learning of experienced operators to improve the standardization of echocardiographic acquisitions

Aims

Impaired standardization of echocardiograms may increase inter-operator variability. This study aimed to determine whether the real-time guidance of experienced sonographers by deep learning (DL) could improve the standardization of apical recordings.

Methods and results

Patients (n = 88) in sinus rhythm referred for echocardiography were included. All participants underwent three examinations, whereof two were performed by sonographers and the third by cardiologists. In the first study period (Period 1), the sonographers were instructed to provide echocardiograms for the analyses of the left ventricular function. Subsequently, after brief training, the DL guidance was used in Period 2 by the sonographer performing the second examination. View standardization was quantified retrospectively by a human expert as the primary endpoint and the DL algorithm as the secondary endpoint. All recordings were scored in rotation and tilt both separately and combined and were categorized as standardized or non-standardized. Sonographers using DL guidance had more standardized acquisitions for the combination of rotation and tilt than sonographers without guidance in both periods (all P ≤ 0.05) when evaluated by the human expert and DL [except for the apical two-chamber (A2C) view by DL evaluation]. When rotation and tilt were analysed individually, A2C and apical long-axis rotation and A2C tilt were significantly improved, and the others were numerically improved when evaluated by the echocardiography expert. Furthermore, all, except for A2C rotation, were significantly improved when evaluated by DL (P < 0.01).

Conclusion

Real-time guidance by DL improved the standardization of echocardiographic acquisitions by experienced sonographers. Future studies should evaluate the impact with respect to variability of measurements and when used by less-experienced operators.

ClinicalTrialsgov Identifier

NCT04580095.