Geometric remodeling of tricuspid valve in pulmonary hypertension and its correlation with pulmonary hypertension severity: a prospectively case-control study using four-dimensional automatic tricuspid valve quantification technology.

Background: Evaluation of the tricuspid valve (TV) is crucial for clinical decision making and post-treatment follow-up in pulmonary hypertension (PH) patients. However, little is known about 4-dimensional (4D) TV geometric remodeling in patients with PH. The aim of this study was to examine the 4D geometry of the TV in PH and its correlation with PH severity. Methods: A total of 74 PH patients with mean pulmonary arterial pressure >25 mmHg and 15 age- and gender-matched healthy individuals were consecutively included from September 2017 to December 2018 in National Center for Cardiovascular Diseases, Fuwai Hospital. All participants underwent 2-dimensional (2D) and 4D transthoracic echocardiography and PH patients underwent right heart catheterization (RHC) within 48 hours of echocardiography. TV geometry was analyzed using a dedicated 4D echocardiography from the right ventricular-focused apical view. Results: Compared with controls, PH patients had significantly larger 4D tricuspid annular (TA) and TV tenting sizes except in the 2-chamber diameter. In high-quality image cases, maximal tenting height (MTH), coaptation point height, tenting volume and 4-chamber diameter had good or moderate correlation with PH severity graded according to RHC mean pulmonary artery pressure (r=0.705, r=0.644, r=0.602, r=0.472, respectively; P<0.001 for all). In multivariable linear regression analysis, PH severity was independently associated with coaptation point height (F=18.070, P<0.001 with an R2=0.647) and MTH (F=25.576, P<0.001 with an R2=0.378). Among all 4D TV parameters, MTH had the highest area under the receiver operating characteristic (ROC) curve (AUC) in high-quality image cases [AUC =0.857, 95% confidence interval (CI): 0.743-0.972; P<0.001], comparable to echocardiographic systolic pulmonary arterial pressure (AUC =0.847, 95% CI: 0.733-0.961; P<0.001). Conclusions: In PH, TV geometric remodeling occurs mainly in TA septal-lateral dimension and TV tenting height. Worsening PH is an independent determinant of TV coaptation point height and MTH, not TA size. MTH shows a great diagnostic potential to detect severe PH.

Utility of Contrast Echocardiography in the Diagnosis of a Primary Nonfunctioning Cardiac Paraganglioma with a Coronary Aneurysm.

Cardiac paragangliomas (PGLs) are rare neuroendocrine tumors, and data regarding the features of nonfunctioning PGLs are limited. These tumors are extensively vascularized and have high risk of hemorrhage for surgery and even biopsy. Differential diagnosis including biochemical analysis of these PGLs is important for further management. In this case report, we present the clinical, laboratory, imaging, and radionuclide presentations of a rare primary nonfunctioning cardiac PGL with a coronary aneurysm. Echocardiography initially showed a large echogenic mass in the left atrioventricular groove. The mass presented a diffuse hyperenhancement pattern with a central perfusion defect on contrast echocardiography. The tumor enclosed the left coronary artery from the coronary orifice, and an aneurysm was found in the left circumflex artery, with significantly increased flow velocity. These echocardiographic features and its susceptible location are indicative of the presence of a cardiac PGL. Although all biochemical evaluations of catecholamines from blood and urine samples were negative, positron emission tomography and scintigraphy finally confirmed the diagnosis of a primary cardiac PGL. Therefore, when imaging features are indicative of the presence of PGLs, the implementation of radionuclide imaging for final diagnosis is required even if the biochemical results are negative. Recognizing these uncommon Doppler and contrast echocardiographic characteristics is important for early diagnosing these nonfunctioning PGLs.

Left atrial reservoir strain measurements derived from intracardiac echocardiography in patients with atrial fibrillation: comparison with transthoracic echocardiography.

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

The Role of the Submitral Apparatus in Hypertrophic Obstructive Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease, is characterized by unexplained hypertrophy of any myocardial segment, and has a prevalence of 0.2% to 0.5% among the general population. As one of the phenotypes of hypertrophic cardiomyopathy, left ventricular outflow tract obstruction (LVOTO) is associated with high morbidity and mortality, including cardiac death. The integration of various factors, including septal hypertrophy, malformation of the mitral valve apparatus, and an anomalous mitral subvalvular apparatus, may contribute to the occurrence of LVOTO. Previous studies have thoroughly discussed the role of the mitral valve in the mechanisms of systolic anterior motion and LVOTO. Recent studies have shown the importance of determining the potential mechanism of the submitral apparatus in inducing systolic anterior motion and LVOTO. The authors review recent advances in knowledge regarding the submitral apparatus of patients with hypertrophic cardiomyopathy.

Change of Left Ventricular Geometric Pattern in Patients with Preserved Ejection Fraction Undergoing Coronary Artery Bypass Grafting.

Left ventricular (LV) remodeling and geometric patterns are associated with variations in prognosis. Two hundred twenty-eight patients who underwent selective isolated coronary artery bypass grafting (CABG) were included, divided into normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy at baseline. More than half participants with normal geometry at baseline remained in that category, and similar ratio of concentric remodeling reverted to normal geometry on follow-up. The concentric hypertrophy at baseline tended to progress to eccentric geometry rather than normal geometry, while changes from eccentric to concentric hypertrophy was uncommon. iLVEDD had a significant association with an increased risk of developing an abnormal geometric pattern from a normal or concentric remodeling pattern, and iLVESD and LAScd involved in the regression from an abnormal geometric pattern. Thus, dynamic changes in LV geometric pattern are common on 1-year follow-up after CABG and LA strain has an incremental role for early detection in this process.

Changes and predictors of secondary mild mitral regurgitation after coronary artery bypass grafting.

BACKGROUND: Secondary mitral regurgitation (SMR) has been related to left ventricular (LV) remodeling and geometric deformation of the mitral apparatus after myocardial infarction (MI), and proved to be associated with adverse cardiac events. We assessed the proportion of mild SMR before and after isolated coronary artery bypass grafting (CABG) surgery, and further study to evaluate dynamic changes of MR and the determinants of such process on 1 year follow-up. METHODS: From 2019 to 2021, cohort study of 171 consecutive hospitalized patients who underwent selective isolated CABG surgery were included and divided into the control group and mild MR group according to whether mild MR occurred at baseline. Univariate analysis and multivariate logistic regression analysis were used to test the associations of changes in MR after CABG, and p < 0.05 was considered significant. RESULTS: The mean age of the cohort was 61.31 ± 8.71 years and 78.95% were male at baseline, divided into the control group (74.85%) and mild MR group (25.15%), respectively. The LV volumetric and size parameters were higher in the mild MR group, with decline in LV and left atrial (LA) strain measurements. About half participants with mild MR at baseline persisted in that category and the rest reverted to none MR on follow-up, while preoperative left main coronary artery occlusion may impede the improvement (p < 0.05). The control group at baseline tended to maintain none MR and one-eighth progressed to mild MR on follow-up, moreover older age and lower LVEF emerged as key correlation of this development. LA volume index (LAVi) was associated with an increased risk of developing mild MR (p < 0.05). CONCLUSIONS: Patients with secondary mild MR had LA dysfunction and CABG surgery promoted regression of MR. LAV has an incremental role for early detection of change in MR over time after surgery.

Bioprosthetic mitral valve stenosis secondary to hypereosinophilic syndrome.

Herein we present a case of hypereosinophilic syndrome (HES) with recurrent involvement of mitral valve. The patient developed mitral regurgitation secondary to HES. Surgical mitral valve replacement was performed successfully. The prosthetic valve dysfunction occurred 3 years later and echocardiography showed severe mitral valve stenosis. Extensive mural thrombi were discovered on both sides of the stenotic valve with eosinophilic infiltration. The patient underwent a repeated mechanical prosthesis replacement and recovered uneventfully.

Global Myocardial Work Combined with Treadmill Exercise Stress to Detect Significant Coronary Artery Disease.

BACKGROUND: Myocardial work (MW) derived from the left ventricular pressure-strain loop is a novel and noninvasive method for assessing left ventricular function that accounts for loading conditions. We aimed to explore whether global MW combined with treadmill exercise stress could detect significant coronary artery disease (CAD) in patients with angina pectoris. METHODS: Eighty-five patients with angina pectoris and no prior CAD history were included. All patients underwent treadmill exercise stress echocardiography and coronary angiography. Global MW was constructed from speckle-tracking echocardiography indexed to the brachial systolic blood pressure. The association between MW parameters and the presence of significant CAD was assessed with logistic regression. The discriminative power of MW parameters to detect CAD was assessed with receiver operative characteristic curve, net reclassification improvement, and integrated discrimination improvement analysis. RESULTS: Twenty-five patients had a positive exercise echocardiogram, while significant coronary artery stenosis (≥70% in one or more major epicardial vessels or ≥50% in the left main coronary artery) was observed in 41 patients. The global wasted work (GWW) and global work efficiency (GWE) were significantly higher or lower, respectively, in patients with significant CAD compared with those of nonsignificant CAD at the peak exercise and during recovery periods (P < .05 for all). Multivariate logistic regression analysis demonstrated that peak GWE and recovery GWW could predict significant CAD. Peak GWE had the highest area under the receiver operating characteristic curve (AUC) among all global MW parameters (AUC = 0.836). Furthermore, a model comprising peak GWE and recovery GWW performed better for the identification of significant CAD than peak GWE alone (AUC = 0.856). CONCLUSIONS: Peak GWE could detect significant CAD. The new model, incorporating peak GWE and recovery GWW, not only identified but also provided additional value for estimating the probability of significant CAD. Global MW parameters combined with exercise stress perform as an accurate noninvasive screening before the invasive diagnostic technique.

Left ventricular basal muscle bundle in hypertrophic cardiomyopathy: insights into the mechanism of left ventricular outflow tract obstruction.

AIMS: Many factors cause left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM). Previous studies reported that left ventricular basal muscle bundle (BMB) may be associated with LVOTO. We aimed to evaluate the role of BMB in LVOTO by echocardiography. METHODS AND RESULTS: Two hundred fifty-six patients diagnosed with HCM were recruited. The morphologic characteristics of left ventricular outflow tract (LVOT) were analysed. BMB was detected in 178 (69.5%) patients by echocardiography. Patients were separated by a resting or provocative LVOT gradient ≥30 mmHg or not. Compared to patients without LVOTO, patients with LVOTO had a significantly thicker basal septum, elongated anterior mitral leaflet (AML), shorter distance between the AML-free margin and the septum or BMB (M-sept/bundle), larger angle between the plane of the mitral valvular orifice and the ascending aorta (MV-AO angle), and higher prevalence of BMB (P < 0.05). According to multivariate analysis, the independent predictors of LVOTO were the presence of BMB, a large basal septum thickness, a short M-sept/bundle, a large MV-AO angle, and a large AML [odds ratio (95% confidence interval): 5.207 (1.381-19.633), 1.386(1.141-1.683), 0.615(0.499-0.756), 1.113(1.054-1.176), and 1.343(1.076-1.677), respectively, P < 0.05]. Of the 256 included patients, 139 underwent surgical myectomy. The transthoracic echocardiography, compared with surgical specimen, showed: sensitivity 98.3%, specificity 82.3%, positive predictive value 97.6%, negative predictive value 87.5%, and accuracy 96.4% to detect BMB. CONCLUSIONS: BMB is common in HCM. BMB is a risk factor for LVOTO.

Quantification of chronic aortic regurgitation using left and right ventricular stroke volumes obtained from two new automated three-dimensional transthoracic echocardiographic software: feasibility and accuracy.

The present study aimed to evaluate the feasibility and accuracy of chronic aortic regurgitation (CAR) quantification using left and right ventricular stroke volumes (LVSV and RVSV, respectively) obtained from two new automated three-dimensional transthoracic echocardiographic software-Dynamic HeartModel (DHM) and 3D Auto RV. Patients (n=116) with more than mild isolated CAR were included and divided into two groups: central (n=53) and eccentric CAR (n=63) groups. LVSV and RVSV were automatically measured by DHM and 3D Auto RV. Next, aortic regurgitant volume (ARVol) was calculated three ways: as the difference between LVSV and RVSV, by the two-dimensional proximal isovelocity surface area (PISA) method, and using effective regurgitant orifice area derived from real-time three-dimensional echocardiography (RT3DE) multiplied by CAR velocity time integral (the reference standard). DHM plus 3D Auto RV correlated well with RT3DE in ARVol measurement in both groups (central, r = 0.90; eccentric, r = 0.96), with no significant difference based on consistency analysis. In the eccentric group, PISA led to an obvious underestimation (mean difference= - 4.20 ml, P < 0.05). The kappa agreement between DHM plus 3D Auto RV and RT3DE in grading CAR severity in both groups was good (central, k = 0.89; eccentric, k = 0.86), but that between PISA and RT3DE in the eccentric CAR group was suboptimal (k = 0.74). This study indicates that ARVol quantification using DHM plus 3D Auto RV is feasible and reproducible in patients with more than mild isolated CAR. This new method has great correlation and agreement with RT3DE in ARVol measurement, with evident advantages over PISA in eccentric CAR.

The Role of Four-Dimensional Automatic Right Ventricular Quantification Technology to Determine RV Function and Hemodynamics in Patients With Pulmonary Hypertension Compared With Right Heart Catheterization.

Background: Four-dimensional automatic right ventricular quantification technology (4D auto-RVQ) is a new method that can simultaneously measure right ventricular (RV) structure and strain. The role of 4D auto-RVQ in determining RV function and hemodynamics is not clear. The role of 4D auto-RVQ in determining RV function and hemodynamics is not clear. We assessed the 4D auto-RVQ to measure right heart structure, function, and hemodynamics in patients with pulmonary hypertension (PHTN) correlated with right heart catheterization (RHC). Methods: We enrolled a prospective cohort of 103 patients with PHTN and 25 healthy controls between September 2017 and December 2018. All patients with PHTN underwent echocardiography and RHC. Patients were included if they underwent two-dimensional (2D) and 4D auto-RVQ echocardiographic sequences on the same day as RHC. We analyzed RV functional indices using 2D and 4D auto-RVQ analyses. We divided patients with PHTN into three groups according to echocardiographic image quality as follows: high (n = 24), average (n = 48), and poor (n = 4). Hemodynamic parameters were measured using RHC, including mean right atrial pressure, mean pulmonary arterial pressure, RV cardiac index (RV-CI), and pulmonary vascular resistance. Results: There were significant differences in most 2D and 4D auto-RVQ parameters between patients with PHTN and healthy controls. Interobserver variability showed significant agreement with 4D auto-RVQ for most measurements except for 4D end-diastolic volume. Indices measured by auto 4D-RVQ in the high-quality image group had a good correlation with RHC but not in the average- and poor-quality image group. Mid-RV diameter showed the best predictive power for the right RV-CI [area under the curve (AUC) 0.935; 95% confidence interval (CI), 0.714-0.997; p < 0.001]. RV end-systolic volume >121.50 mL had a 71.43% sensitivity and a 100% specificity to predict right RV-CI (AUC, 0.890; 95% CI, 0.654-0.986; p < 0.001). Conclusions: 4D auto-RVQ may be used to estimate RV function and some hemodynamic changes compared with RHC in PHTN patients with high image quality. Furthermore, a large sample of the study is needed to evaluate RV function by 4D auto-RVQ in PHTN patients with average image quality.

Current status and etiology of valvular heart disease in China: a population-based survey.

BACKGROUND: The epidemiology of valvular heart disease (VHD) has changed markedly over the last 50 years worldwide, and the prevalence and features of VHD in China are unknown. The objective of this study was to investigate the current status and etiology of VHD in China. METHODS: We used a cross-sectional national survey with stratified multistage random sampling from the general Chinese population to estimate the VHD burden. Data on demographic characteristics, medical history, physical examination, blood tests, and potential etiology were collected. Echocardiography was used to detect VHD. RESULTS: The national survey enrolled 34,994 people aged 35 years or older across China. Overall, 31,499 people were included in the final analysis, and 1309 participants were diagnosed with VHD. The weighted prevalence was 3.8%, with an estimated 25 million patients in China. The prevalence of VHD increased with age and was higher in participants with hypertension or chronic kidney disease than in their counterparts. Among participants with VHD, 55.1% were rheumatic and 21.3% were degenerative. The proportion of rheumatic decreased with age, and the proportion of degenerative rose with age. However, the prevalence of rheumatic disease was still higher in the elderly population than in the younger population. Logistic regression revealed that age and hypertension were correlated with VHD. CONCLUSIONS: In China, rheumatic heart disease was still the major cause of the VHD, with a significant increase in degenerative heart disease. Age and hypertension are important and easily identifiable markers of VHD.

Patients who do not fulfill criteria for hypertrophic cardiomyopathy but have unexplained giant T-wave inversion: a cardiovascular magnetic resonance mid-term follow-up study.

BACKGROUND: Patients who have unexplained giant T-wave inversions but do not meet criteria for hypertrophic cardiomyopathy (HCM) (left ventricular (LV) wall thickness < 1.5 cm) demonstrate LV apical morphological features that differ from healthy subjects. Currently, it remains unknown how the abnormal LV apical morphology in this patient population changes over time. The purpose of this study was to investigate LV morphological and functional changes in these patients using a mid-term cardiovascular magnetic resonance (CMR) exam. METHODS: Seventy-one patients with unexplained giant T-wave inversion who did not fulfill HCM criteria were studied. The mean interval time of the follow-up CMR was 24.4 ± 8.3 months. The LV wall thickness was measured in each LV segment according to the American Heart Association 17-segmented model. The apical angle (ApA) was also measured. A receiver operating curve (ROC) was used to identify the predictive values of the CMR variables. RESULTS: Of 71 patients, 16 (22.5%) progressed to typical apical HCM, while 55 (77.5%) did not progress to HCM criteria. The mean apical wall thickness was significantly different between the two groups at both baseline and follow-up, with the apical HCM group having greater wall thickness at both time points (all p < 0.001). There was a significant difference between the two groups in the change of ApA (- 1.5 ± 2.7°/yr vs. - 0.7 ± 2.0°/yr, p < 0.001) over time. The combination of mean apical wall thickness and ApA proved to be the best predictor for fulfilling criteria for apical HCM with a threshold value of 8.1 mm and 90° (sensitivity 93.8%, specificity 85.5%). CONCLUSIONS: CMR metrics identify predictors for progression to HCM in patients with unexplained giant T-wave inversion.

Comparison of Myocardial Layer-Specific Strain and Global Myocardial Work Efficiency During Treadmill Exercise Stress in Detecting Significant Coronary Artery Disease.

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

Left atrial reservoir strain combined with E/E' as a better single measure to predict elevated LV filling pressures in patients with coronary artery disease.

BACKGROUND: The 2016 guidelines for left ventricular diastolic dysfunction diagnosis has been simplified from previous versions; however, multiparametric diagnosis approach still exists indeterminate left ventricular diastolic dysfunction category. Left atrial (LA) strain was recently found useful to predict elevated left ventricular (LV) filling pressures noninvasively. This study aimed to (1) analyze the diagnostic value of LA strain for noninvasive assessment of LV filling pressures in patients with stable coronary artery disease (CAD) with preserved LV ejection fraction (LVEF), using invasive hemodynamic assessment as the gold standard, and (2) explore whether LA strain combined with conventional diastolic parameters could detect elevated LV filling pressures alone. METHODS: Sixty-four patients with stable CAD having LVEF > 50% and 30 healthy controls were enrolled. Two-dimensional speckle-tracking echocardiography was used to measure LA strain during the reservoir (LASr), conduit, and contraction phases. LV end-diastolic pressure (LVEDP), as a surrogate for LV filling pressures, was invasively obtained by left heart catheterization. Logistic regression was used to calculate the odds ratio to predict LV filling pressures. Pearson's correlation was used to analyze associations between echocardiographic parameters and LVEDP. The area under the receiver-operating characteristic curve was calculated to determine the capability of the echocardiographic parameters to detect elevated LVEDP. Inter-technique agreement was analyzed by contingency tables and tested by kappa statistics. RESULTS: LASr and the ratio of early-diastolic transmitral flow velocity (E) to tissue Doppler early-diastolic septal mitral annular velocity (E/E'septal) significantly predicted elevated LV filling pressures. LASr was combined with E/E'septal to generate a novel parameter (LASr/E/E'septal). LASr/E/E'septal had the best predictive ability of elevated LV filling pressures. LVEDP was negatively correlated with LASr and LASr/E/E'septal but positively correlated with E/E'septal. The area under the receiver-operating characteristic curve of LASr/E/E'septal was higher than that of LASr alone (0.83 vs. 0.75), better than all conventional LV diastolic parameters. Inter-technique agreement analysis showed that LASr/E/E'septal had good agreement with the invasive LVEDP measurement, better than the 2016 guideline (kappa = 0.63 vs. 0.25). CONCLUSIONS: LASr provided additive diagnostic value for the noninvasive assessment of LV filling pressures. LASr/E/E'septal had the potential to be a better single noninvasive index to predict elevated LV filling pressures in patients with stable CAD and preserved LVEF.

Validation of methods for effective orifice area measurement of prosthetic valves by two-dimensional and Doppler echocardiography following transcatheter self-expanding aortic valve implantation.

BACKGROUND: The effective orifice area (EOA) is utilized to characterize the hemodynamic performance of the transcatheter heart valve (THV). However, there is no consensus on EOA measurement of self-expanding THV. We aimed to compare two echocardiographic methods for EOA measurement following transcatheter self-expanding aortic valve implantation. METHODS: EOA was calculated according to the continuity equation. Two methods were constructed. In Method 1 and Method 2, the left ventricular outflow tract diameter (LVOTd) was measured at the entry of the prosthesis (from trailing-to-leading edge) and proximal to the prosthetic valve leaflets (from trailing-to- leading edge), respectively. The velocity-time integral (VTI) of the LVOT (VTILVOT) was recorded by pulsed-wave Doppler (PW) from apical windows. The region of the PW sampling should match that of the LVOTd measurement with precise localization. The mean transvalvular pressure gradient (MG) and VTI of THV was measured by Continuous wave Doppler. RESULTS: A total of 113 consecutive patients were recruited. The mean age was 77.2 ± 5.5 years, and 72 patients (63.7%) were male. EOA1 with the use of Method 1 was larger than EOA2 (1.56 ± 0.39 cm2 vs. 1.48 ± 0.41 cm2, P = 0.001). MG correlated better with the indexed EOA1 (EOAI1) (r = -0.701, P < 0.001) than EOAI2 (r = -0.645, P < 0.001). According to EOAI (EOAI ≤ 0.65 cm2/m2, respectively), the proportion of sever prosthesis-patient mismatch with the use of EOA1 was lower than EOA2 (12.4% vs. 21.2%, P < 0.05). Compared with EOA2, EOA1 had lower interobserver and intra-observer variability (intra: 0.5% ± 17% vs. 3.8% ± 22%, P < 0.001; inter: 1.0% ± 9% vs. 3.5% ± 11%, P < 0.001). CONCLUSIONS: For transcatheter self-expanding valve EOA measurement, LVOTd should be measured in the entry of the prosthesis stent (from trailing-to-leading edge), and VTILVOT should match that of the LVOTd measurement with precise localization.

Prevalence of heart failure and left ventricular dysfunction in China: the China Hypertension Survey, 2012-2015.

BACKGROUND: Heart failure (HF) is a major health burden worldwide. However, there is no nationwide epidemiological data on HF in China after 2000. The aims of this study are (i) to determine the prevalence of left ventricular (LV) dysfunction and HF (with reduced, mid-range, and preserved ejection fraction) in a nationally representative Chinese population, and (ii) to investigate the treatment and control of hypertension in HF patients. METHODS AND RESULTS: Data from the China Hypertension Survey (CHS) and 22 158 participants were eligible for analysis in this study. For each participant, a self-reported history of HF and any other cardiovascular diseases was acquired. Two-dimensional and Doppler echocardiography was used to assess LV dysfunction. Overall, 1.3% (estimated 13.7 million) of the Chinese adult population aged ≥35 years had HF, 1.4% of participants had LV systolic dysfunction (ejection fraction <50%), and 2.7% were graded as having 'moderate' or 'severe' LV diastolic dysfunction. The weighted prevalence of HF was similar between urban and rural residents (1.6% vs. 1.1%, P = 0.266), and between men and women (1.4% vs. 1.2%, P = 0.632). In addition, among HF patients with hypertension, 57.7% received antihypertensive medication, and 14.5% had their blood pressure controlled <140/90 mmHg. CONCLUSIONS: In summary, there was an increase in the prevalence of HF, and LV dysfunction was very common in China. However, treatment and control of hypertension in participants with HF were low. CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR-ECS-14004641.

Recognition of Ultrasound Artifact Mimicking Pulmonary Artery Dissection in Patients with Heart Disease.

PURPOSE: Imaging artifacts are frequently encountered when performing clinical echocardiography. Based on our review of the literature, two-dimensional linear artifacts are mainly reported in the ascending aorta in patients with suspected aortic dissections. However, pulmonary artery artifacts that mimic pulmonary artery dissection have not been discussed. We herein report our experience with children and adults with preexisting heart conditions and pulmonary artery imaging artifacts. METHODS: The study population comprised 10 patients with heart disease who were treated at our hospital from March 2015 to September 2017. Nine patients were children with congenital heart disease, mainly patent ductus arteriosus (n = 8), and one patient was an adult with pulmonary artery hypertension. Transthoracic echocardiography was performed in all patients. RESULTS: We confirmed the diagnosis in six patients during a surgical operation for other indications and in four patients by computed tomographic pulmonary angiography. The most common pulmonary imaging artifact was observed from the left high parasternal view (9/10, 90%). Most of the artifacts were diagonally oriented (8/10, 80%), and a few were horizontally oriented. Half of the artifacts were located in the main pulmonary arteries with mild pulmonary artery dilatation. Pulmonary hypertension was seen only in the adult patient. The thymus gland was clearly seen in young patients. CONCLUSION: Pulmonary artery imaging artifacts in patients with preexisting heart disease during echocardiographic examination can mimic pulmonary artery dissection. Understanding the types and origins of these ultrasound artifacts is important to avoid a false-positive diagnosis.

A feasible method for non-invasive measurement of pulmonary vascular resistance in pulmonary arterial hypertension: Combined use of transthoracic Doppler-echocardiography and cardiac magnetic resonance. Non-invasive estimation of pulmonary vascular resistance.

BACKGROUND: Transthoracic Doppler-echocardiography (TTE) can estimate mean pulmonary arterial pressure (MPAP) and pulmonary capillary wedge pressure (PCWP) reliably, and cardiac magnetic resonance (CMR) is the best modality for non-invasive measurement of cardiac output (CO). We speculated that the combined use of TTE and CMR could provide a feasible method for non-invasive measurement of pulmonary vascular resistance (PVR) in pulmonary arterial hypertension (PAH). METHODS AND RESULTS: Right heart catheterization (RHC) was undertaken in 77 patients (17M/60F) with PAH, and simultaneous TTE was carried out to evaluate MPAP, PCWP and CO. Within 2 days, CO was measured again with CMR in similar physiological status. Then, PVR was calculated with the integrated non-invasive method: TTE-derived (MPAP-PCWP)/CMR-derived CO and the isolated TTE method: TTE-derived (MPAP-PCWP)/TTE-derived CO, respectively. The PVR calculated with integrated non-invasive method correlated well with RHC-calculated PVR (r = 0.931, 95% confidence interval 0.893 to 0.956). Between the integrated non-invasive PVR and RHC-calculated PVR, the Bland-Altman analysis showed the satisfactory limits of agreement (mean value: - 0.89 ± 2.59). In comparison, the limits of agreement were less satisfactory between TTE-calculated PVR and RHC-calculated PVR (mean value: - 1.80 ± 3.33). Furthermore, there were excellent intra- and inter-observer correlations for the measurements of TTE and CMR (P < 0.001 for all). CONCLUSIONS: The combined use of TTE and CMR provides a clinically reliable method to determine PVR non-invasively. In comparison with RHC, the integrated method shows good accuracy and repeatability, which suggests the potential for the evaluation and serial follow-up in patients with PAH. TRANSLATIONAL PERSPECTIVE: In PAH, the non-invasive measurement of PVR is very important in clinical practice. Up to now, however, the widely accepted non-invasive method is still unavailable. Since TTE can estimate (MPAP-PCWP) reliably and CMR is the best image modality for the measurement of CO, the combined use of two modalities has the potential to determine PVR non-invasively. In this research, the integrated non-invasive method showed good diagnostic accuracy and repeatability compared with RHC. Therefore, it might be a feasible method for non-invasive measurement of PVR in patients with PAH.

Influence of percutaneous atrial septal defect closure on inter- and intra-ventricular mechanical dyssynchrony in adults: evaluation of strain pattern.

Previous studies using speckle-tracking echocardiography (STE) for quantifying the functions of the right and left ventricles (RV and LV, respectively) in the presence of percutaneous atrial septal defect (ASD) closure have focused on the peak systolic strain (PSS). This study investigated changes in the mechanical dyssynchrony of ventricular contraction before and after ASD closure, issues that have been little addressed in the literature. Thirty-one adults with ASD were studied using two-dimensional STE before and 24 h after ASD closure. Thirty-one healthy age- and sex-matched subjects were recruited as controls. Global and segmental PSS values from the longitudinal, circumferential, and radial directions were analyzed. The time to peak systolic strain (PSST) and the standard deviation of the time to peak strain (SDT) among segments in each direction were calculated, to investigate the inter- and intra-ventricular mechanical dyssynchrony in these patients and improvements after closure. Compared to the control group, patients with ASD had higher RV free-wall longitudinal systolic strain, with increased PSST and SDT. The SDT values of the LV longitudinal and circumferential strains were also increased. By 24 h after ASD closure, the RV free-wall longitudinal strain and its PSST and SDT had reverted to normal levels. The LV circumferential strain was increased, and its SDT was decreased. The contraction period of the RV and myocardial contraction dyssynchrony in the RV and LV were increased in ASD patients. The inter- and intra-ventricular mechanical utilities were improved after percutaneous closure of the ASD.