Simulation-based echocardiography learning contribution on training of medical residents.

INTRODUCTION: Echocardiography is a pivotal exam in critically ill patients, a specific training is crucial. Medical residents often lack echocardiography practice. AIM: This study aims to evaluate the impact of simulation-based training on medical residents' echocardiography mastery. METHODS: This interventional study was conducted among medical residents at the Simulation Center of the Faculty of Medicine in Monastir (CeSim) in January 2022. The intervention consisted of a theoretical training and a simulator-based practical training concerning echocardiography. Residents underwent evaluation before and after training through a "Pre-Test" and a "Post-Test," respectively, using a French-language questionnaire. Participation was entirely voluntary. RESULTS: A total of 28 medical residents participated in our study, with the majority being female (57.1%). The median age was 29 years (interquartile range: 28-31.75). Following training, the proportion of participants who reported having the necessary skills for echocardiography interpretation significantly increased (p<0.05). Respondents demonstrated significant improvements in their scores on theoretical tests and practical skills assessments. Concerning echocardiographic views, the percentage of participants who correctly identified the title of the parasternal small axis section increased from 53.6% before training to 100% after training (p <10-3). Significant enhancements were observed in all parameters evaluating the practice of echocardiographic sections by respondents on a mannequin after training, encompassing time to obtain the view, view quality, image quality, visualization of structures, interpretability, and image stability (p<10-3). There was a significant improvement in average response rates for echocardiographic clinical syndroms among medical residents before and after training. All participants emphasized the indispensability of ultrasound education in the training of physicians specializing in managing cardiopulmonary emergencies. CONCLUSIONS: This study reports the beneficial role of simulation-based training in enhancing the mastery of medical residents in echocardiography. Incorporating such training methods into their learning curricula is advisable.

Left Atrial Strain for assessment of left ventricle diastolic dysfunction in acute coronary syndrome patients.

INTRODUCTION: Patients with acute coronary syndrome (ACS) have a high incidence of Left ventricle diastolic dysfunction (DD). Latest algorithms for the assessment of DD lay on 2D parameters and describe a grading to quantify its severity. However, there persists a "gray zone" of values in which DD remains indeterminate. AIM: to analyze the diagnostic value of Left atrium strain (LAS) for categorization of LV DD and assessment of LV filling pressures in ACS patients. METHODS: Cross-sectional study that prospectively evaluated 105 patients presenting ACS with preserved LV ejection fraction (LVEF). Patients were divided in 4 groups according to the DD grade. Mean values of LAS, corresponding to three phases of atrial function: reservoir (LASr), conduit (LAScd) and contraction (LASct), were obtained by speckle-tracking echocardiography. RESULTS: Mean age was 60±10 years, with a gender ratio of 6.14. LASr and LASct were significantly lower according to DD severity (p combined=0.021, p combined=0.034; respectively). E/e' ratio was negatively correlated to LASr (r= - 0.251; p= 0.022) and LASct (r= -0.197; p=0.077). Left atrial volume index (LAVI) was also negatively correlated to LASr (r= -0.294, p= 0.006) and LASct (r= -0.3049, p=0.005). Peak tricuspid regurgitation was negatively correlated to LASr (r=-0.323, p=0.017) and LASct (r=-0.319, p=0.020). Patients presenting elevated LV filling pressures had lower LASr and LASct (p=0.049, p=0.022, respectively) compared to patients witn normal LV filling pressures. ROC curve analysis showed that a LASr < 22% (Se= 75%, Sp= 73%) and a LASct < 13% (Se= 71%, Sp=58%) can increase the likelihood of DD grade II or III by 4.6 (OR= 4.6; 95% CI: 1.31-16.2; p=0.016) and 3.7 (OR= 3.7; 95% CI: 1.06-13.1; p= 0.047), respectively. CONCLUSION: LAS is a valuable tool, which can be used to categorize DD in ACS patients.

Assessment of the Ischaemic Effects of Myocardial Bridge by Echocardiographic Exercise Stress Test.

Background: Detection of myocardial bridge (MB) at angiography suggests it has a role in ischaemic-related symptoms in patients with angina without obstructive coronary artery disease. However, evidence that MB may cause myocardial ischaemia is limited. Methods: We studied 41 patients with MB of the left anterior descending coronary artery and otherwise normal coronary arteries. Fourteen patients with normal coronary arteries and without MB served as controls. All subjects underwent a maximal treadmill exercise stress test (EST) under ECG monitoring. Standard and speckle-tracking echocardiography were performed at baseline and immediately after peak EST. Results: EST duration and peak heart rate and systolic pressure were similar in the two groups. A positive EST (ST-segment depression .1 mm) was found in 18 patients in the MB group (43.9%) and none in the control group (p=0.001). No abnormalities in both left ventricle systolic and diastolic function were found between the two groups in the standard echocardiographic evaluation. Global and segmental (anterior, inferior) longitudinal strain (LS) did not differ at baseline between the groups. There was a small increase in global LS during EST in MB patients but not in the control group (p=0.01). Similar trends were found for regional LSs, with differences being significant for the medium (p=0.028) and apical (p=0.032) anterior segments. No differences in echocardiographic parameters and both global and segmental LSs were observed between MB patients with ischaemic ECG changes during EST versus those without. Conclusion: Our findings do not support the notion that MB results in significant degrees of myocardial ischaemia during maximal myocardial work.

Evaluation of left ventricular systolic function in type 2 diabetes mellitus patients with and without peripheral vascular disease.

BACKGROUND: Peripheral vascular disease (PVD) is a common complication of type 2 diabetes mellitus (T2DM). Patients with T2DM have twice the risk of PVD as nondiabetic patients. AIM: To evaluate left ventricular (LV) systolic function by layer-specific global longitudinal strain (GLS) and peak strain dispersion (PSD) in T2DM patients with and without PVD. METHODS: Sixty-five T2DM patients without PVD, 57 T2DM patients with PVD and 63 normal controls were enrolled in the study. Layer-specific GLS [GLS of the epimyocardium (GLSepi), GLS of the middle myocardium (GLSmid) and GLS of the endocardium (GLSendo)] and PSD were calculated. Receiver operating characteristic (ROC) analysis was performed to calculate the sensitivity and specificity of LV systolic dysfunction in T2DM patients with PVD. We calculated Pearson's correlation coefficients between biochemical data, echocardiographic characteristics, and layer-specific GLS and PSD. RESULTS: There were significant differences in GLSepi, GLSmid and GLSendo between normal controls, T2DM patients without PVD and T2DM patients with PVD (P < 0.001). Trend tests revealed a ranking of normal controls > T2DM patients without PVD > T2DM patients with PVD in the absolute value of GLS (P < 0.001). PSD differed significantly between the three groups, and the trend ranking was as follows: normal controls < T2DM patients without PVD < T2DM patients with PVD (P < 0.001). ROC analysis revealed that the combination of layer-specific GLS and PSD had high diagnostic efficiency for detecting LV systolic dysfunction in T2DM patients with PVD. Low-density lipoprotein cholesterol was positively correlated with GLSepi, GLSmid and PSD (P < 0.05), while LV ejection fraction was negatively correlated with GLSepi, GLSmid and GLSendo in T2DM patients with PVD (P < 0.01). CONCLUSION: PVD may aggravate the deterioration of LV systolic dysfunction in T2DM patients. Layer-specific GLS and PSD can be used to detect LV systolic dysfunction accurately and conveniently in T2DM patients with or without PVD.

Subclinical impairment of left ventricular myocardium function in type 2 diabetes mellitus patients with or without hypertension.

BACKGROUND: Cardiovascular disease has been the leading cause of morbidity and mortality for type 2 diabetes mellitus (T2DM) patients over the last decade. AIM: To determine whether layer-specific global longitudinal strain (GLS) combined with peak strain dispersion (PSD) can be used to assess left ventricle (LV) myocardium systolic dysfunction in T2DM patients or without hypertension (HP). METHODS: We enrolled 97 T2DM patients, 70 T2DM + HP patients and 101 healthy subjects. Layer-specific GLS and PSD were calculated by EchoPAC software in apical three-, four- and two-chamber views. GLS of the epimyocardial, middle-layer and endomyocardial (GLSepi, GLSmid, and GLSendo) were measured and recorded. Receiver operating characteristic analysis was performed to detect LV myocardium systolic dysfunction in T2DM patients. RESULTS: There were significant differences in GLSepi, GLSmid, GLSendo, and PSD between healthy subjects, T2DM patients and T2DM patients with HP (P < 0.001). Trend tests yielded the ranking of healthy subjects > T2DM patients > T2DM with HP patients in the absolute values of GLSepi, GLSmid and GLSendo (P < 0.001), while PSD was ranked healthy subjects < T2DM < T2DM with HP (P < 0.001). Layer-specific GLS and PSD had high diagnostic efficiency for detecting LV myocardium systolic dysfunction in T2DM patients, however, the area under the curve (AUC) for layer-specific GLS and PSD combined was significantly higher than the AUCs for the individual indices (P < 0.05). CONCLUSION: Layer-specific GLS and PSD were associated with LV myocardium systolic dysfunction in T2DM patients, T2DM patients with HP. T2DM patients with HP have more severe LV myocardium systolic dysfunction than T2DM patients without HP and normal control patients. The combination of layer-specific GLS and PSD may provide additional prognostic information for T2DM patients with or without HP.

Cardiac gene delivery using ultrasound: State of the field.

Over the past two decades, there has been tremendous and exciting progress toward extending the use of medical ultrasound beyond a traditional imaging tool. Ultrasound contrast agents, typically used for improved visualization of blood flow, have been explored as novel non-viral gene delivery vectors for cardiovascular therapy. Given this adaptation to ultrasound contrast-enhancing agents, this presents as an image-guided and site-specific gene delivery technique with potential for multi-gene and repeatable delivery protocols-overcoming some of the limitations of alternative gene therapy approaches. In this review, we provide an overview of the studies to date that employ this technique toward cardiac gene therapy using cardiovascular disease animal models and summarize their key findings.

Automated Quality Assessment of Medical Images in Echocardiography Using Neural Networks with Adaptive Ranking and Structure-Aware Learning.

The quality of medical images is crucial for accurately diagnosing and treating various diseases. However, current automated methods for assessing image quality are based on neural networks, which often focus solely on pixel distortion and overlook the significance of complex structures within the images. This study introduces a novel neural network model designed explicitly for automated image quality assessment that addresses pixel and semantic distortion. The model introduces an adaptive ranking mechanism enhanced with contrast sensitivity weighting to refine the detection of minor variances in similar images for pixel distortion assessment. More significantly, the model integrates a structure-aware learning module employing graph neural networks. This module is adept at deciphering the intricate relationships between an image's semantic structure and quality. When evaluated on two ultrasound imaging datasets, the proposed method outshines existing leading models in performance. Additionally, it boasts seamless integration into clinical workflows, enabling real-time image quality assessment, crucial for precise disease diagnosis and treatment.

Left atrial appendage occlusion and patent foramen ovale closure using a steerable sheath and intracardiac echocardiography.

A patient presenting with acute ischemic stroke associated with patent foramen ovale (PFO) had concurrent deep vein thrombosis, pulmonary embolism, and new-onset atrial fibrillation. Upon initiation of anticoagulation therapy, the patient developed hemorrhagic transformation of the stroke. The patient's multiple potential sources of embolic stroke were treated with concomitant left atrial appendage occlusion and PFO closure through the PFO, made possible by using the Steerable Amulet Sheath under 3D-intracardiac echocardiography guidance.

Opportunistic Screening of Chronic Liver Disease with Deep Learning Enhanced Echocardiography.

Importance: Chronic liver disease affects more than 1.5 billion adults worldwide, however the majority of cases are asymptomatic and undiagnosed. Echocardiography is broadly performed and visualizes the liver; but this information is not leveraged. Objective: To develop and evaluate a deep learning algorithm on echocardiography videos to enable opportunistic screening for chronic liver disease. Design: Retrospective observational cohorts. Setting: Two large urban academic medical centers. Participants: Adult patients who received echocardiography and abdominal imaging (either abdominal ultrasound or abdominal magnetic resonance imaging) with ≤30 days between tests, between July 4, 2012, to June 4, 2022. Exposure: Deep learning model predictions from a deep-learning computer vision pipeline that identifies subcostal view echocardiogram videos and detects the presence of cirrhosis or steatotic liver disease (SLD). Main Outcome and Measures: Clinical diagnosis by paired abdominal ultrasound or magnetic resonance imaging (MRI). Results: A total of 1,596,640 echocardiogram videos (66,922 studies from 24,276 patients) from Cedars-Sinai Medical Center (CSMC) were used to develop EchoNet-Liver, an automated pipeline that identifies high quality subcostal images from echocardiogram studies and detects the presence of cirrhosis or SLD. In the held-out CSMC test cohort, EchoNet-Liver was able to detect the presence of cirrhosis with an AUC of 0.837 (0.789 - 0.880) and SLD with an AUC of 0.799 (0.758 - 0.837). In a separate test cohort with paired abdominal MRIs, cirrhosis was detected with an AUC of 0.704 (0.689-0.718) and SLD was detected with an AUC of 0.726 (0.659-0.790). In an external test cohort of 106 patients (n = 5,280 videos), the model detected cirrhosis with an AUC of 0.830 (0.738 - 0.909) and SLD with an AUC of 0.768 (0.652 - 0.875). Conclusions and Relevance: Deep learning assessment of clinical echocardiography enables opportunistic screening of SLD and cirrhosis. Application of this algorithm may identify patients who may benefit from further diagnostic testing and treatment for chronic liver disease.

Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis.

IMPORTANCE: Guidelines recommend the use of Dobutamine stress echocardiography (DSE) in patients with low-gradient aortic stenosis (AS) and left ventricular ejection fraction (LVEF) <50%. However, a paucity exists in DSE data when LVEF>35%. OBJECTIVE: To examine the diagnostic accuracy of DSE, in patients with low-gradient AS with a wide range of LVEF and to examine the interaction between the diagnostic accuracy of DSE and LVEF. DESIGN, SETTING AND PARTICIPANTS: Patients with mean-gradient<40 mmHg, AVA<1.0 cm2, and stroke volume index≤35 mL/m2 undergoing DSE and Cardiac Computer Tomography (C-CT) were identified from three prospectively collected patient cohorts, and stratified according to LVEF; LVEF<35%, LVEF 35-50% & LVEF>50%. EXPOSURE: DSE and C-CT was performed on patients with low-gradient AS MAIN OUTCOMES AND MEASURES: Severe AS was defined as AVC score ≥2000 AU among men, and ≥1200 AU for women on C-CT. RESULTS: Of 221 patients included in the study, 78 (35%) presented with LVEF<35%, 67 (30%) with LVEF 35-50%, and 76 (34%) with LVEF>50%. Mean-gradient and Vmax during DSE showed significantly diagnostic heterogeneity between LVEF groups, being most precise when LVEF<35% (both AUC=0.90), albeit with optimal thresholds of 30 mmHg & 377 cm/s, and a limited diagnostic yield in patients with LVEF≥35% (AUC=0.67 & 0.66 in LVEF 35-50% and AUC=0.65 & 0.60 in LVEF≥50%). Using guideline thresholds led to a sensitivity/specificity of 49%/84% for all patients with LVEF<50%. CONCLUSION AND RELEVANCE: While DSE is safe and leads to an increase in stroke volume in patients with low-gradient AS regardless of LVEF, the association between DSE gradients and AS severity assessed by C-CT demonstrates important heterogeneity depending on LVEF, with highest accuracy in patients with LVEF<35%.

Association between Mobility of Residual Left Atrial Thrombus and Stroke Severity in Patients with Nonvalvular Atrial Fibrillation.

BACKGROUND: The differences in the characteristics of ischemic stroke associated with a mobile versus nonmobile residual left atrial thrombus (LAT) are unclear. We investigated whether the mobility of an LAT detected by transthoracic echocardiography is associated with the clinical features of stroke. METHODS: This study included 20 consecutive patients with nonvalvular atrial fibrillation who were admitted to our hospital for treatment of acute ischemic stroke and then found to have an LAT on transthoracic echocardiography. The patients were divided into two groups: those with a mobile LAT (Group M) and those with a nonmobile LAT (Group N). The clinical, neuroradiological, and echocardiographic variables were assessed. RESULTS: The LAT was mobile in 11 patients (Group M) and nonmobile in nine patients (Group N). The median National Institutes of Health Stroke Scale score on admission was higher in Group M than N (17 vs. 7, respectively; p=0.196). Four patients in Group M and one in Group N developed in-hospital stroke recurrence (36% vs. 11%, respectively; p=0.319). The prevalence of large vessel occlusion (15 events in Group M and 10 events in Group N, including in-hospital recurrent events) was significantly higher in Group M than N (73% vs. 30%, respectively; p=0.049), which seemed to lead to poorer functional outcomes in Group M than N (ratio of modified Rankin scale score of 0-2 at discharge: 18% vs. 44%, respectively; p=0.336). CONCLUSIONS: The mobility of LAT may affect stroke severity in patients with nonvalvular atrial fibrillation.

Artificial intelligence-enhanced automation of left ventricular diastolic assessment: a pilot study for feasibility, diagnostic validation, and outcome prediction.

Background: Evaluating left ventricular diastolic function (LVDF) is crucial in echocardiography; however, the complexity and time demands of current guidelines challenge clinical use. This study aimed to develop an artificial intelligence (AI)-based framework for automatic LVDF assessment to reduce subjectivity and improve accuracy and outcome prediction. Methods: We developed an AI-based LVDF assessment framework using a nationwide echocardiographic dataset from five tertiary hospitals. This framework automatically identifies views, calculates diastolic parameters, including mitral inflow and annular velocities (E/A ratio, e' velocity, and E/e' ratio), maximal tricuspid regurgitation velocity, left atrial (LA) volume index, and left atrial reservoir strain (LARS). Subsequently, it grades LVDF according to guidelines. The AI-framework was validated on an external dataset composed of randomly screened 173 outpatients who underwent transthoracic echocardiography with suspicion for diastolic dysfunction and 33 individuals from medical check-ups with normal echocardiograms at Seoul National University Bundang Hospital, tertiary medical center in Korea, between May 2012 and June 2022. Additionally, we assessed the predictive value of AI-derived diastolic parameters and LVDF grades for a clinical endpoint, defined as a composite of all-cause death and hospitalization for heart failure, using Cox-regression risk modelling. Results: In an evaluation with 200 echocardiographic examinations (167 suspected diastolic dysfunction patients, 33 controls), it achieves an overall accuracy of 99.1% in identifying necessary views. Strong correlations (Pearson coefficient 0.901-0.959) were observed between AI-derived and manually-derived measurements of diastolic parameters, including LARS as well as conventional parameters. When following the guidelines, whether utilizing AI-derived or manually-derived parameters, the evaluation of LVDF consistently showed high concordance rates (94%). However, both methods exhibited lower concordance rates with the clinician's prior assessments (77.5% and 78.5%, respectively). Importantly, both AI-derived and manually-derived LVDF grades independently demonstrated significant prognostic value [adjusted hazard ratio (HR) =3.03; P=0.03 and adjusted HR =2.75; P=0.04, respectively] for predicting clinical outcome. In contrast, the clinician's prior grading lost its significance as a prognostic indicator after adjusting for clinical risk factors (adjusted HR =1.63; P=0.36). AI-derived LARS values significantly decreased with worsening LVDF (P for trend <0.001), and low LARS (<17%) was associated with increased risk for the clinical outcome (Log-rank P=0.04) relative to that for preserved LARS (≥17%). Conclusions: Our AI-based approach for automatic LVDF assessment on echocardiography is feasible, potentially enhancing clinical diagnosis and outcome prediction.

Giant Left Ventricular Thrombus Rapidly Developing in an Extremely Short Period of Time in a Patient With Severe Systolic Dysfunction.

Although left ventricular thrombi (LVTs) are closely related to the prognosis of patients with systolic dysfunction, anticoagulation therapy is not recommended for the primary prevention of LVTs in patients with sinus rhythm heart failure. We report a case of a patient with systolic dysfunction who developed a giant LVT in an extremely short period of time (one month) after an infection. The LVT led to acute limb ischemia, gangrene, and death. Additionally, we incidentally detected pulmonary thrombosis in this patient.

Tricuspid Papillary Fibroelastoma: A Rare Tumor in an Uncommon Location.

Papillary fibroelastomas (PFEs) are rare benign cardiac tumors typically arising from the valvular endocardium, often affecting the aortic and mitral valves. They can range from asymptomatic to causing severe thromboembolic complications like stroke. This article presents a case of a tricuspid valve PFE in an 81-year-old patient with severe multi-vessel coronary artery disease. Transthoracic echocardiography revealed a mass on the tricuspid valve, confirmed by cardiac MRI. The patient underwent surgical excision, and histopathology confirmed the PFE diagnosis. The case highlights the importance of multimodal imaging in diagnosis and individualized treatment strategies for valvular heart tumors.

Transesophageal Echocardiographic Evaluation of Coronary Blood Flow and the Initial Flap Assisting in the Surgical Decision-Making: A Case of Acute Type A Aortic Dissection.

Acute aortic dissection is a life-threatening condition. Myocardial ischemia associated with dissection occurs due to direct extension into the coronary artery or indirect involvement of the coronary ostia secondary to the dissection flap. Thus, the surgical procedure may require coronary reconstruction, in addition to aortic replacement. We experienced a case in which coronary artery reconstruction could be avoided because intraoperative transesophageal echocardiography showed that the aortic flap did not obstruct the right coronary artery in systole, and pulsed Doppler imaging indicated that there was sufficient coronary blood flow. This case shows that it is critical to establish a correct and early diagnosis and to proceed with the appropriate treatment for patients with myocardial ischemia.

Amelanotic Melanoma Invading the Heart.

We present a case of a middle-aged woman who initially presented with shortness of breath but was ultimately found to have a large mass-like lesion in the right atrium of the heart with multi-modality imaging including cardiac computed tomography, cardiac magnetic resonance imaging, and echocardiogram. Biopsy results were positive for amelanotic melanoma. The patient underwent extensive debridement surgery, and she was started on chemotherapy with a close follow-up with an oncologist. In the setting of an aggressive course of disease, unfortunately, the patient passed away secondary to sudden cardiac arrest.  Cardiac melanoma, also known as melanoma of the heart, is an extremely rare type of melanoma that originates in the heart. This case attributes to the professional growth and competency of healthcare providers involved in the care of patients with cardiac melanoma, ultimately aiming to optimize patient outcomes and quality of life. Due to its rarity and the challenges associated with its diagnosis and treatment, prognosis for cardiac melanoma is generally poor. However, advancement in cancer research and treatment may offer hope for improved outcomes in some cases.