Optimización de la interpretación de ecocardiogramas con la utilización de Machine Learning en el estudio WASE / Optimizing Echocardiograms Interpretation with the Application of Machine Learning in the WASE Study

RESUMEN Introducción: El número creciente de estudios ecocardiográficos y la necesidad de cumplir rigurosamente con las recomendaciones de guías internacionales de cuantificación, ha llevado a que los cardiólogos deban realizar tareas sumamente extensas y repetitivas, como parte de la interpretación y análisis de cantidades de información cada vez más abrumadoras. Novedosas técnicas de machine learning (ML), diseñadas para reconocer imágenes y realizar mediciones en las vistas adecuadas, están siendo cada vez más utilizadas para responder a esta necesidad evidente de automatización de procesos. Objetivos: Nuestro objetivo fue evaluar un modelo alternativo de interpretación y análisis de estudios ecocardiográficos, basado fundamentalmente en la utilización de software de ML, capaz de identificar y clasificar vistas y realizar mediciones estandarizadas de forma automática. Material y métodos: Se utilizaron imágenes obtenidas en 2000 sujetos normales, libres de enfermedad, de los cuales 1800 fueron utilizados para desarrollar los algoritmos de ML y 200 para su validación posterior. Primero, una red neuronal convolucional fue desarrollada para reconocer 18 vistas ecocardiográficas estándar y clasificarlas de acuerdo con 8 grupos (stacks) temáticos. Los resultados de la identificación automática fueron comparados con la clasificación realizada por expertos. Luego, algoritmos de ML fueron desarrollados para medir automáticamente 16 parámetros de eco Doppler de evaluación clínica habitual, los cuales fueron comparados con las mediciones realizadas por un lector experto. Finalmente, comparamos el tiempo necesario para completar el análisis de un estudio ecocardiográfico con la utilización de métodos manuales convencionales, con el tiempo necesario con el empleo del modelo que incorpora ML en la clasificación de imágenes y mediciones ecocardiográficas iniciales. La variabilidad inter e intraobservador también fue analizada. Resultados: La clasificación automática de vistas fue posible en menos de 1 segundo por estudio, con una precisión de 90 % en imágenes 2D y de 94 % en imágenes Doppler. La agrupación de imágenes en stacks tuvo una precisión de 91 %, y fue posible completar dichos grupos con las imágenes necesarias en 99% de los casos. La concordancia con expertos fue excelente, con diferencias similares a las observadas entre dos lectores humanos. La incorporación de ML en la clasificación y medición de imágenes ecocardiográficas redujo un 41 % el tiempo de análisis y demostró menor variabilidad que la metodología de interpretación convencional. Conclusión: La incorporación de técnicas de ML puede mejorar significativamente la reproducibilidad y eficiencia de las interpretaciones y mediciones ecocardiográficas. La implementación de este tipo de tecnologías en la práctica clínica podría resultar en reducción de costos y aumento en la satisfacción del personal médico.

ABSTRACT Background: The growing number of echocardiographic tests and the need for strict adherence to international quantification guidelines have forced cardiologists to perform highly extended and repetitive tasks when interpreting and analyzing increasingly overwhelming amounts of data. Novel machine learning (ML) techniques, designed to identify images and perform measurements at relevant visits, are becoming more common to meet this obvious need for process automation. Objectives: Our objective was to evaluate an alternative model for the interpretation and analysis of echocardiographic tests mostly based on the use of ML software in order to identify and classify views and perform standardized measurements automatically. Methods: Images came from 2000 healthy subjects, 1800 of whom were used to develop ML algorithms and 200 for subsequent validation. First, a convolutional neural network was developed in order to identify 18 standard echocardiographic views and classify them based on 8 thematic groups (stacks). The results of automatic identification were compared to classification by experts. Later, ML algorithms were developed to automatically measure 16 Doppler scan parameters for regular clinical evaluation, which were compared to measurements by an expert reader. Finally, we compared the time required to complete the analysis of an echocardiographic test using conventional manual methods with the time needed when using the ML model to classify images and perform initial echocardiographic measurements. Inter- and intra-observer variability was also analyzed. Results: Automatic view classification was possible in less than 1 second per test, with a 90% accuracy for 2D images and a 94% accuracy for Doppler scan images. Stacking images had a 91% accuracy, and it was possible to complete the groups with any necessary images in 99% of cases. Expert agreement was outstanding, with discrepancies similar to those found between two human readers. Applying ML to echocardiographic imaging classification and measurement reduced time of analysis by 41% and showed lower variability than conventional reading methods. Conclusion: Application of ML techniques may significantly improve reproducibility and efficiency of echocardiographic interpretations and measurements. Using this type of technologies in clinical practice may lead to reduced costs and increased medical staff satisfaction.

Limitations of apical sparing pattern in cardiac amyloidosis: a multicentre echocardiographic study.

AIMS: Although impaired left ventricular (LV) global longitudinal strain (GLS) with apical sparing is a feature of cardiac amyloidosis (CA), its diagnostic accuracy has varied across studies. We aimed to determine the ability of apical sparing ratio (ASR) and most common echocardiographic parameters to differentiate patients with confirmed CA from those with clinical and/or echocardiographic suspicion of CA but with this diagnosis ruled out. METHODS AND RESULTS: We identified 544 patients with confirmed CA and 200 controls (CTRLs) as defined above (CTRL patients). Measurements from transthoracic echocardiograms were performed using artificial intelligence software (Us2.AI, Singapore) and audited by an experienced echocardiographer. Receiver operating characteristic curve analysis was used to evaluate the diagnostic performance and optimal cut-offs for the differentiation of CA patients from CTRL patients. Additionally, a group of 174 healthy subjects (healthy CTRL) was included to provide insight on how patients and healthy CTRLs differed echocardiographically. LV GLS was more impaired (-13.9 ± 4.6% vs. -15.9 ± 2.7%, P < 0.0005), and ASR was higher (2.4 ± 1.2 vs. 1.7 ± 0.9, P < 0.0005) in the CA group vs. CTRL patients. Relative wall thickness and ASR were the most accurate parameters for differentiating CA from CTRL patients [area under the curve (AUC): 0.77 and 0.74, respectively]. However, even with the optimal cut-off of 1.67, ASR was only 72% sensitive and 66% specific for CA, indicating the presence of apical sparing in 32% of CTRL patients and even in 6% healthy subjects. CONCLUSION: Apical sparing did not prove to be a CA-specific biomarker for accurate identification of CA, when compared with clinically similar CTRLs with no CA.

Deep learning assisted measurement of echocardiographic left heart parameters: improvement in interobserver variability and workflow efficiency.

Machine learning techniques designed to recognize views and perform measurements are increasingly used to address the need for automation of the interpretation of echocardiographic images. The current study was designed to determine whether a recently developed and validated deep learning (DL) algorithm for automated measurements of echocardiographic parameters of left heart chamber size and function can improve the reproducibility and shorten the analysis time, compared to the conventional methodology. The DL algorithm trained to identify standard views and provide automated measurements of 20 standard parameters, was applied to images obtained in 12 randomly selected echocardiographic studies. The resultant measurements were reviewed and revised as necessary by 10 independent expert readers. The same readers also performed conventional manual measurements, which were averaged and used as the reference standard for the DL-assisted approach with and without the manual revisions. Inter-reader variability was quantified using coefficients of variation, which together with analysis times, were compared between the conventional reads and the DL-assisted approach. The fully automated DL measurements showed good agreement with the reference technique: Bland-Altman biases 0-14% of the measured values. Manual revisions resulted in only minor improvement in accuracy: biases 0-11%. This DL-assisted approach resulted in a 43% decrease in analysis time and less inter-reader variability than the conventional methodology: 2-3 times smaller coefficients of variation. In conclusion, DL-assisted approach to analysis of echocardiographic images can provide accurate left heart measurements with the added benefits of improved reproducibility and time savings, compared to conventional methodology.

Value of 3D echocardiography in the diagnosis of arrhythmogenic right ventricular cardiomyopathy.

AIMS: The 2010 Task Force Criteria (TFC) require that both right ventricular (RV) regional wall-motion abnormalities (WMA) and specific RV size cut-offs be met in order to fulfil one of the major criterion for arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis. Currently, 2D echocardiography (2DE) and cardiovascular magnetic resonance imaging (cMRI) are used to determine if these criteria are met. Little is known about the diagnostic value of 3D echocardiography (3DE) in ARVC. The aim of this study was to determine whether a combination of 2DE-3DE is non-inferior to the currently used 2DE-cMRI combination in the diagnosis of patients with ARVC. METHODS AND RESULTS: Thirty-nine individuals (47±15 years) with suspected ARVC underwent evaluation of the RV with cMRI, 2DE, and 3DE. 3DE and cMRI were independently used to obtain RV volumes, ejection fraction (EF) and determine the presence of segmental RV WMA. Studies were blindly classified as meeting criteria for ARVC in accordance with the 2010 TFC. Kappa statistics were used to test the concordance between 2DE-cMRI and 2DE-3DE approaches. Using the 2DE-cMRI approach, 3/39 were not affected, 5/39 possible, 8/39 borderline, and 23/39 definite ARVC. The proposed 2DE-3DE approach yielded 5/39 not affected, 7/39 possible, 8/39 borderline, and 19/39 definite diagnoses. The two approaches were highly concordant (k = 0.71; 95% confidence interval: 0.44-0.84). Although 3DE underestimated RV volumes in comparison with cMRI, interfering, in some instances with the fulfilment of a major criterion, it was able to identify more RV WMA (28/39) than 2DE (11/39), with a detection-rate comparable to cMRI (33/39) highlighting a unique advantage. CONCLUSION: The combination of 2DE-3DE for ARVC diagnosis is comparable to the conventional 2DE-cMRI approach. 3DE should be performed in all suspected ARVC patients to aide in the detection of WMA.

Normative values of the aortic valve area and Doppler measurements using two-dimensional transthoracic echocardiography: results from the Multicentre World Alliance of Societies of Echocardiography Study.

AIMS: Aortic valve area (AVA) used for echocardiographic assessment of aortic stenosis (AS) has been traditionally interpreted independently of sex, age and race. As differences in normal values might impact clinical decision-making, we aimed to establish sex-, age- and race-specific normative values for AVA and Doppler parameters using data from the World Alliance Societies of Echocardiography (WASE) Study. METHODS AND RESULTS: Two-dimensional transthoracic echocardiographic studies were obtained from 1903 healthy adult subjects (48% women). Measurements of the left ventricular outflow tract (LVOT) diameter and Doppler parameters, including AV and LVOT velocity time integrals (VTIs), AV mean pressure gradient, peak velocity, were obtained according to ASE/EACVI guidelines. AVA was calculated using the continuity equation. Compared with men, women had smaller LVOT diameters and AVA values, and higher AV peak velocities and mean gradients (all P < 0.05). LVOT and AV VTI were significantly higher in women (P < 0.05), and both parameters increased with age in both sexes. AVA differences persisted after indexing to body surface area. According to the current diagnostic criteria, 13.5% of women would have been considered to have mild AS and 1.4% moderate AS. LVOT diameter and AVA were lower in older subjects, both men and women, and were lower in Asians, compared with whites and blacks. CONCLUSION: WASE data provide clinically relevant information about significant differences in normal AVA and Doppler parameters according to sex, age, and race. The implementation of this information into clinical practice should involve development of specific normative values for each ethnic group using standardized methodology.

Abnormal Longitudinal Strain Reduction of Basal Left Ventricular Segments in Patients Recovered of COVID-19.

Background: The Severe acute respiratory syndrome coronavirus 2, is the pathogen that causes COVID-19. Cardiovascular (CV) involvement during this infection, has been related to adverse outcomes. Interestingly, some patients may remain symptomatic beyond the first 14 days of disease diagnosis. Although a particular reduction on left ventricular (LV) global longitudinal strain (GLS) in basal segments has been recently described in patients hospitalized with diagnosis of COVID-19, the correlation of these findings with the persistence of symptoms has not been determined. Objectives: The objective of this study is to describe echocardiographic findings in patients recovered from COVID-19 and to determine its association with persistent dyspnea. Methods: Seventy-six patients were analyzed. Forty-six were asymptomatic (group N°1) and 30 referred persistent dyspnea at the time of examination (group N°2), and a cohort of 25 healthy individuals was included as a control group. Total LV GLS, average basal LV GLS, and average mid-apical LV GLS were assessed. Basal-mid-apical index (BMAI) was calculated. A difference in BMAI bigger than 15% between both groups was stablished as cutoff point. Results: Nonsignificative differences on standard echocardiographic measurements were found between the analyzed groups. When compared to the control group, there was nonsignificative reduction on basal LV GLS values in patients with persistent dyspnea. However, BMAI values were bigger than 15% in 70% of patients from group N°2 but in none of the patients from the control group ( = 0.0002). Conclusions: This new index allowed to identify an abnormal relation in LV GLS values between basal and medium-apical segments among patients recovered from COVID-19 and persistent dyspnea.

Normal Values of Left Atrial Size and Function and the Impact of Age: Results of the World Alliance Societies of Echocardiography Study.

BACKGROUND: Left atrial (LA) evaluation includes volumetric and functional parameters with an abundance of diagnostic and prognostic implications. Solid normal reference ranges are compulsory for accurate interpretation in individual patients, but previous studies have yielded mixed conclusions regarding the effects of age, sex, and/or race. The present report from the World Alliance Societies of Echocardiography study focuses on two-dimensional (2D) and three-dimensional (3D) measures of LA structure and function, with subgroup analysis by age, sex, and race. METHODS: Transthoracic 2D and 3D echocardiographic images were obtained in 1,765 healthy individuals (901 men, 864 women) evenly distributed among age subgroups: 18 to 40 years (n = 745), 41 to 65 years (n = 618), and >65 years (n = 402); the racial distribution was 38.4% white, 39.9% Asian, and 9.7% black. Images were analyzed using dedicated LA analysis software to measure LA volumes and phasic function from 3D volume and 2D strain curves. RESULTS: Three-dimensional maximum and minimum LA volumes adjusted for body surface area were nearly identical for men and women, but women demonstrated higher 3D total and passive emptying fractions (EFs). Two-dimensional reservoir strain was similar for both sexes. Age was associated with an incremental rise in LA volumes alongside characteristic shifts in functional indices. Total 2D EF and reservoir and conduit strain varied inversely with age, counteracted by higher booster strain, with a greater magnitude of effect in women. Active 3D EF was significantly higher, while total and passive EFs decreased with age. Interracial differences were noted in LA volumes, without substantial differences in functional indices. CONCLUSION: Although similar normal values for LA volumes and strain can be applied to both sexes, meaningful differences in LA size occur with aging. Indices of function also shift with age, with a compensatory rise in booster function, which may serve to counteract observed lower total and passive EFs. Defining age-associated normal values may help differentiate age-associated "healthy" LA aging from pathologic processes.

Aortic and Mitral Disease due to an Unusual Etiology.

Relapsing polychondritis (RP) is a rare multisystem disease characterized by inflammation in cartilaginous structures and other connective tissues throughout the body, affecting the ears, nose, eyes, joints, respiratory tract, heart, and blood vessels. Cardiovascular involvement is the second most common cause of mortality after laryngotracheal involvement.[1] Here, we report a successful surgical case of RP in which the patient underwent aortic and mitral valve replacement and concomitant coronary artery bypass grafting.

Placenta percreta con invasión a vejiga; reporte de un caso y descripción de la técnica quirúrgica / Placenta percreta with invasion of the bladder: case report and description of surgical technique

La placenta percreta es una de las variedades de acretismo placentario más graves, con consecuencias catas-tróficas, entidad rara con alta morbimortalidad materno-fetal. Se reporta un caso de una paciente de 18 años con antecedente de una cesárea, que cursó con embarazo de 36 semanas de gestación y acude por sangrado transvaginal. Durante su estancia se corrobora diagnóstico de placenta previa parcial y acretismo placentario. Durante la laparotomía se observa placenta percreta con invasión a vejiga. Actualmente hay diversos abordajes quirúrgicos, todos encaminados a disminuir complicaciones asociadas; en este caso se realizó cesárea-histerectomía modificada como una alternativa terapéutica a considerar

Placenta percreta is one of the most serious varieties of placental accreta, with catastrophic consequences, a rare entity with high maternal-fetal morbidity and mortality. We report a case of an 18-year-old woman with a history of a cesarean section, who was pregnant at 36 weeks of gestation and went for transvaginal bleeding. During her stay, diagnosis of partial placenta previa and placental accreta was corroborated. During the laparotomy she was observed placenta percreta with bladder invasion. There are currently several surgical approaches, all aimed at reducing associated complications; in this case modified cesarean-hysterectomy was performed as a therapeutic alternative to be considered

Machine learning based automated dynamic quantification of left heart chamber volumes.

AIMS: Studies have demonstrated the ability of a new automated algorithm for volumetric analysis of 3D echocardiographic (3DE) datasets to provide accurate and reproducible measurements of left ventricular and left atrial (LV, LA) volumes at end-systole and end-diastole. Recently, this methodology was expanded using a machine learning (ML) approach to automatically measure chamber volumes throughout the cardiac cycle, resulting in LV and LA volume-time curves. We aimed to validate ejection and filling parameters obtained from these curves by comparing them to independent well-validated reference techniques. METHODS AND RESULTS: We studied 20 patients referred for cardiac magnetic resonance (CMR) examinations, who underwent 3DE imaging the same day. Volume-time curves were obtained for both LV and LA chambers using the ML algorithm (Philips HeartModel), and independently conventional 3DE volumetric analysis (TomTec), and CMR images (slice-by-slice, frame-by-frame manual tracing). Automatically derived LV and LA volumes and ejection/filling parameters were compared against both reference techniques. Minor manual correction of the automatically detected LV and LA borders was needed in 4/20 and 5/20 cases, respectively. Time required to generate volume-time curves was 35 ± 17 s using ML algorithm, 3.6 ± 0.9 min using conventional 3DE analysis, and 96 ± 14 min using CMR. Volume-time curves obtained by all three techniques were similar in shape and magnitude. In both comparisons, ejection/filling parameters showed no significant inter-technique differences. Bland-Altman analysis confirmed small biases, despite wide limits of agreement. CONCLUSION: The automated ML algorithm can quickly measure dynamic LV and LA volumes and accurately analyse ejection/filling parameters. Incorporation of this algorithm into the clinical workflow may increase the utilization of 3DE imaging.

Detección de anomalías de posición mediante ultrasonido transabdominal suprapúbico. Reporte de dos casos / Detection of position anomalies by suprapubic transabdominal ultrasound. Report of two cases

Resumen ANTECEDENTES: Las anomalías de posición fetal se asocian con la deficiente evolución de trabajo de parto. El ultrasonido durante el trabajo de parto es una herramienta complementaria para confirmar los hallazgos obtenidos en la exploración vaginal y definir el tipo de anomalía de posición fetal. CASOS CLÍNICOS: Caso 1: Paciente de 24 años, primigesta, con 41 semanas de embarazo y ruptura prematura de membranas. Ingresó al área de tococirugía por completar la dilatación y borramiento cervical, sin evolución del trabajo de parto durante 120 minutos. El ultrasonido transabdominal suprapúbico reportó el signo de estrabismo. El embarazo finalizó por cesárea y se corroboró la anomalía fetal de posición occipito-posterior. Caso 2: Paciente de 29 años, primigesta, con 39 semanas de embarazo e hipertensión gestacional, quien completó la dilatación y borramiento cervical y durante 120 minutos no hubo descenso del polo cefálico. A la exploración vaginal se detectó variedad de posición fetal occipito-transversa. El ultrasonido transabdominal suprapúbico mostró el signo de estrabismo. El embarazo finalizó mediante cesárea y la evolución para la madre y su hijo fue satisfactoria. CONCLUSIONES: La ecografía es un estudio efectivo para la detección de anomalías de posición, pues disminuye las complicaciones materno-fetales asociadas con trabajo de parto extendido. Sin embargo, reportar la experiencia de solo dos casos no podría tener validez para sustentar dicha afirmación.

Abstract BACKGROUND: The anomalies of the position are the cause of failure in the task of labor. The ultrasound during labor is a complementary tool to confirm the clinical findings in the vaginal examination and define the type of position abnormality. OBJECTIVE: to report on the use of ultrasound during abnormal labor, such as the detection of the position abnormality. CLINICAL CASES: Case 1: 24-year-old patient with 41 weeks of gestation (SDG) and premature rupture of membranes, entered the area of tochosurgery to complete the dilation and cervical neck, nevertheless worked and delivery for 120 minutes . A suprapubic transabdominal ultrasound was performed, finding a sign of strabismus, the resolution was by caesarean section and an occipito-posterior position anomaly was corroborated. Case 2: 29-year-old patient with 39 SDG and gestational hypertension, it is deduced from the labor, the cervical neck was dilated and for 120 minutes, there was no decrease of the cephalic pole, a variety of occipito place -transverse, suprapubic transabdominal ultrasound was performed, finding a sign of strabismus. The pregnancy ended by caesarean section and the evolution for the mother and her child was satisfactory. CONCLUSIONS: Ultrasound is an effective study for the detection of position abnormalities, since it reduces maternal-fetal complications associated with extended labor. However, reporting the experience of only two cases could not be valid to support this assertion.

Hemorragia obstétrica secundaria a placenta previa y leiomioma retroplacentario gigante cervical. Reporte de un caso / Obstetric hemorrhage secondary to placenta previa and giant retroplacental leiomyoma cervical. Case report

Resumen ANTECEDENTES: Los leiomiomas y el embarazo se relacionan con complicaciones impredecibles; incluso su incidencia se ha incrementado, debido al retraso de la primera gestación y conforme avanza la edad de la madre, su asociación con hemorragia posparto y alto riesgo de histerectomía obstétrica aumentan la morbilidad y mortalidad. CASO CLÍNICO: Paciente de 30 años, sin control prenatal y embarazo clínicamente de término, que acudió a urgencias por dolor obstétrico y sangrado transvaginal. En la exploración física reveló el primer periodo de trabajo de parto, 9 cm de dilatación, altura de presentación -4 según los planos De Lee; se palpó el borde placentario a nivel cervical, acompañado de sangrado transvaginal moderado, rojo rutilante. Se activó el código mater y se preparó para cesárea, por placenta previa sangrante. Durante la intervención quirúrgica se comprobó el diagnóstico y la tumoración, que inició en la cara posterior, en el segmento uterino inferior, y finalizó en la zona cervical, con múltiples vasos de neoformación sangrantes y atonía uterina secundaria, circunstancias que condicionaron hemorragia importante. Se efectuó la histerectomía obstétrica y nació una niña de 3145 g, talla 51 cm, Capurro de 41 semanas de gestación y Apgar 7/9. La pérdida hemática total fue de 2000 cc; permaneció cuatro días en estancia hospitalaria y la madre y su hijo se dieron de alta del hospital sin complicaciones. CONCLUSIÓN: La relación entre miomatosis uterina y embarazo incrementa el riesgo de complicaciones maternas. El seguimiento ecográfico y el control prenatal determinan su repercusión durante la evolución del embarazo y el parto. En estos casos es importante considerar el tratamiento conservador.

Abstract BACKGROUND: Leiomyomas and gestation are an association with unpredictable complications, in which their incidence is increased by the delay of the first gestation and as maternal age advances, its relationship with postpartum hemorrhage and high risk of obstetric hysterectomy increases maternal morbidity and mortality proportionally. CLINICAL CASE: A 30-year-old patient without prenatal care and a clinically terminal pregnancy, who attended the emergency department due to obstetric pain and transvaginal bleeding. Physical examination revealed first labor, 9cm of dilation, height of presentation -4 according to plans From Lee, placental edge was palpated at the cervical level, accompanied by moderate transvaginal bleeding, bright red, mater code is activated and prepared for cesarean section, for bleeding placenta, during the surgical event, corroborates diagnosis and tumor that starts on the face posterior, lower uterine segment and ends at the cervical level, with multiple vessels of bleeding neoformation and secondary uterine atony, causing significant hemorrhage, obstetric hysterectomy was performed, a new born with sex female woman with a weight of 3145 g, size 51cm, Capurro 41 weeks of gestation was obtained, Apgar 7/9, the total blood loss was 2000 cc, 4 days of inpatient hospital stay, the binomial without complications was graduated. CONCLUSION: The association of uterine myomatosis and pregnancy increase the risk of maternal complications, adequate ultrasound monitoring and prenatal control, determine the repercussion during the evolution of pregnancy and childbirth, conservative management should always be considered.

Feasibility of Left Ventricular Global Longitudinal Strain Measurements from Contrast-Enhanced Echocardiographic Images.

BACKGROUND: Although left ventricular global longitudinal strain (GLS) is an index of systolic function recommended by the guidelines, poor image quality may hamper strain measurements. While contrast agents are commonly used to improve endocardial visualization, no commercial speckle-tracking software is able to measure strain in contrast-enhanced images. This study aimed to test the accuracy of speckle-tracking software when applied to contrast-enhanced images in patients with suboptimal image quality. METHODS: We studied patients with a wide range of GLS values who underwent transthoracic echocardiography. Protocol 1 included 44 patients whose images justified use of contrast but still allowed noncontrast speckle-tracking echocardiography (STE), which was judged as accurate and used as a reference. Protocol 2 included 20 patients with poor image quality that precluded noncontrast STE; cardiac magnetic resonance- (CMR-) derived strain was used as the reference instead. Half the manufacturer recommended dose of a commercial contrast agent (Definity/Optison/Lumason) was used to provide partial contrast enhancement. Higher than normal mechanical indices (0.6-0.7) and lowest frequency range for maximal penetration settings were used for imaging. GLS was measured (Epsilon) with and without contrast-enhanced images and by CMR-derived feature tracking (TomTec). Comparisons included linear regression and Bland-Altman analyses. RESULTS: The contrast STE analysis failed in 4/64 patients (6%). Manual corrections were needed to optimize tracking with contrast in all patients. GLS measurements were in good agreement between contrast and noncontrast images (r = 0.85; mean GLS in the contrast images, -12.9% ± 4.7%; bias, 0.34% ± 2.4%). Good agreement was also noted between contrast STE- and CMR-derived strain (r = 0.83; mean, GLS -13.5% ± 4.0%; bias, 0.72% ± 2.5%). CONCLUSIONS: We found that GLS measurements from contrast-enhanced images are feasible and accurate in most patients, even in those with poor image quality that precludes strain measurements without contrast enhancement.

Women's experiences with legal abortion in Mexico City: a qualitative study.

In April 2007, elective first-trimester abortion was legalized in Mexico City. As of June 2011, more than 60,000 women from Mexico City and other Mexican states have obtained legal abortions in the city's public hospitals and health centers, with private facilities providing additional abortion services. This study examines women's experiences of abortion services in one public and two private clinic settings in 2008. Twenty-five in-depth interviews were conducted: 15 with women who obtained abortions in a public health center and 10 who obtained the procedure at either of two private clinics. Participants were highly satisfied with services at both public and private sites, although some had to go to more than one site before receiving services. None expressed doubts about their decision to have an abortion, and they felt unanimously that they were treated with respect. Furthermore, participants were pleased with the counseling they received and most accepted a contraceptive method after the procedure.

Percutaneous mitral valve repair: a feasibility study in an ovine model of acute ischemic mitral regurgitation.

Annuloplasty is the cornerstone of surgical mitral valve repair. A percutaneous transvenous catheter-based approach for mitral valve repair was tested by placing a novel annuloplasty device in the coronary sinus of sheep with acute ischemic mitral regurgitation. Mitral regurgitation was reduced from 3-4+ to 0-1+ in all animals (P < 0.03). The annuloplasty functioned by reducing septal-lateral mitral annular diameter (30 +/- 2.1 mm preinsertion vs. 24 +/- 1.7 mm postinsertion; P < 0.03). These preliminary experiments demonstrate that percutaneous mitral annuloplasty is feasible. Further study is necessary to demonstrate long-term safety and efficacy of this novel approach.