Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA): Echocardiographic diagnosis in a critically ill newborn.

ARCAPA echocardiographic diagnosis. A network of small multiple coronary vessels, a systo-diastolic jet of flow into the pulmonary artery and a retrograde inverted «blue¼ flow into the RCA are the key signs. CT-scan confirms the diagnosis .

Prognostic value of extraaortic-valvular cardiac damage in patients with moderate aortic stenosis and reduced left ventricular ejection fraction.

PURPOSE: The extraaortic-valvular cardiac damage (EVCD) Stage has shown potential for risk stratification for patients with aortic stenosis (AS). This study aimed to examine the usefulness of the EVCD Stage in risk stratification of patients with moderate AS and reduced left ventricular ejection fraction (LVEF). METHODS: Clinical data from patients with moderate AS (aortic valve area, .60-.85 cm2/m2; peak aortic valve velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20%-50%) were analyzed during 2010-2019. Patients were categorized into three groups: EVCD Stages 1 (LV damage), 2 (left atrium and/or mitral valve damage), and 3/4 (pulmonary artery vasculature and/or tricuspid valve damage or right ventricular damage). The primary endpoint included a composite of cardiac death and heart failure hospitalization, with non-cardiac death as a competing risk. RESULTS: The study included 130 patients (mean age 76.4 ± 6.8 years; 62.3% men). They were categorized into three groups: 26 (20.0%) in EVCD Stage 1, 66 (50.8%) in Stage 2, and 48 (29.2%) in Stage 3/4. The endpoint occurred in 54 (41.5%) patients during a median follow-up of 3.2 years (interquartile range, 1.4-5.1). Multivariate analysis indicated EVCD Stage 3/4 was significantly associated with the endpoint (hazard ratio 2.784; 95% confidence interval 1.197-6.476; P = .017) compared to Stage 1, while Stage 2 did not (hazard ratio 1.340; 95% confidence interval .577-3.115; P = .500). CONCLUSION: The EVCD staging system may aid in the risk stratification of patients with moderate AS and reduced LVEF.

Right Ventricular-Pulmonary Arterial Coupling and Outcome in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Right ventricular-pulmonary artery coupling (RVPAC) refers to the relationship between right ventricular systolic force and afterload. The ratio of echocardiograph-derived tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) has been proposed as a noninvasive measurement of RVPAC and reported as an independent prognostic parameter of heart failure. However, it has not been adequately in detail evaluated in heart failure with preserved ejection fraction (HFpEF). We hypothesized that RVPAC may be used and proposed as an expression of key risk factors in patients with HFpEF. METHODS: We retrospectively analyzed TAPSE/PASP of 648 HFpEF patients hospitalized in Chongqing Hospital of Traditional Chinese Medicine from January 1, 2016 to January 1, 2017. All eligible patients were followed up for 5 years. The correlation between TAPSE/SPAP index and clinical indicators and outcomes was evaluated. RESULTS: The final analysis included 414 patients. Nonsurvivors had significantly lower TAPSE, TAPSE/PASP and higher PASP compared with survivors (p < 0.0001). ROC curve analysis showed that the optimal cutoff of TAPSE, PASP, and RVPAC to predict all-cause death were 16.5 mm, 37.5 mmHg, and 0.45 mm/mmHg, respectively. In multivariate Cox regression analyses adjusted for gender showed a significant, independent association of the RVPAC with the composite endpoint of all-cause death or HF-related recurrent hospitalization (HR: 0.006; 95% CI 0.001-0.057, p < 0.001). CONCLUSIONS: RVPAC, defined by the ratio of TAPSE to PASP, is the expression of a key risk factor in HFpEF patients, which is independently associated with the composite endpoint of all-cause death or HF-related recurrent hospitalization.

Retractable congestive heart failure due to sinus valsalva rupture with coexisting gerbode defect: a rare case report.

Sinus of Valsalva aneurysm (SoVA) is a rare disease with less than 1% prevalence in the population. Most cases are asymptomatic, however, significant clinical manifestations are possible due to fistula formation and sudden rupture resulting in cardiac shunt. Eventually it may develop into progressive heart failure with high morbidity. We report the case of a 33 year old female patient who presented with shortness of breath, ascites, and recurring hospitalisation. The cardiac examination revealed sinus tachycardia along with loud and continuous murmurs on the left parasternal border. Several standard diagnostic procedures could not be performed due to malignant arrhythmia in supine position. Echocardiography examination revealed SoV rupture with a gerbode defect, which was the underlying cause of severe retractable heart failure.

Cardiac myxoma as a rare acute heart failure etiology in paediatrics: A case report.

Cardiac myxoma is extremely rare in children. However, if not treated immediately, it may cause varying symptoms until sudden death. A-9-years old male Javanese child was brought to the emergency department of Prof. Soekandar General Hospital, Mojokerto with progressive dyspnoea since one month which got worse in the left decubitus position. There was no significant past medical history. Physical examination revealed hypotension, mitral stenosis, tricuspid regurgitation, and pulmonary congestion. Transthoracic echocardiography revealed a round pedunculated 3x3.3 cm mass in the Left Atrium that swingingly moved to the Left Ventricle during diastole. This was diagnosed provisionally as Myxoma with a differential of thrombus. After stabilization, he was referred to a tertiary hospital for emergency excision. Histopathology confirmed the myxoma. There were no symptoms and activity limitations during the 6 months follow-up. To the best of our knowledge, this is the first paediatric cardiac myxoma with Acute Heart Failure symptoms reported in Indonesia. Echocardiography is imperative for diagnosing myxoma. Appropriate and timely management results in an excellent outcome.

Myocardial injury mimicking acute myocardial infarction due to coronavirus infection in adults with pre-existing apical hypertrophic cardiomyopathy.

Symptoms of apical hypertrophic cardiomyopathy (ApHCM) can mimic acute myocardial infarction (AMI). Following COVID-19 infection, the elevation of troponin in ApHCM might be confusing, due to its similarity with AMI. We report the case of a 64-year-old male patient presenting with exertional dyspnoea and chest discomfort. He had no history of coronary artery disease (CAD), but his swab test was positive for COVID-19. The physical examination was normal. The 12-lead electrocardiogram showed a sinus rhythm of 78 bpm, with deep inverted T waves in leads V2 to V6, I, and aVL, and left ventricular hypertrophy. An Echocardiographic examination showed an 18 mm apical wall thickness of the left ventricle. Laboratory tests revealed elevated hs- Troponin level, but diagnostic coronary angiography was normal. The diagnostic criteria fulfilled apical cardiac hypertrophic cardiomyopathy. Coronavirus can induce atypical cardiovascular symptoms in pre-existing ApHCM. Misdiagnosis and failure to recognize may result in inappropriate therapy and delay in definitive treatment.

Angiotensin converting enzyme inhibitor and coenzyme Q10 as adjunctive treatment for patients with ventricular septal rupture following late onset myocardial infarction: a case report.

Ventricular Septal Rupture (VSR) is a rare complication of acute myocardial infarction and has a high mortality rate. Surgery is the definitive treatment. However, in hospitals with limited facilities, treating acute myocardial infarction patients with ventricular septal rupture, is challenging. A 74-year-old woman came to the emergency room of Dr. Koesma General Hospital, Tuban, East Java in December, 2019 with late-onset Acute Myocardial Infarction. On the following day, a new holosystolic murmur was heard in the left lower sternal border with palpable thrill. Transthoracic echocardiography showed VSR with severe pulmonary hypertension. This was followed by a drop in the blood pressure to 80/50 mmHg. The blood pressure was dependent on vasopressors until lisinopril and coenzyme Q10 were introduced. After 3 months, the haemodynamics of the patient were stable. This proved that the use of angiotensin-converting enzyme and coenzyme Q10 promotes more energy production, enables tissue healing and leads to balanced remodelling to increase the survival rate in cases of non-surgical treatment.

Initial experience with zero-fluoroscopy pulmonary vein isolation in patients with atrial fibrillation: single-center observational trial.

Pulmonary vein isolation (PVI) stands as a widely practiced cardiac ablation procedure on a global scale, conventionally guided by fluoroscopy. The concurrent application of electroanatomical mapping systems (EAMS) and intracardiac echocardiography offers a means to curtail radiation exposure. This study aimed to compare procedural outcomes between conventional and our initial zero-fluoroscopy cases in patients with paroxysmal or persistent atrial fibrillation (AF), undergoing point-by-point PVI. Our prospective observational study included 100 consecutive patients with AF who underwent point-by-point radiofrequency PVI. The standard technique was used in the first 50 cases (Standard group), while the fluoroless technique was used in the subsequent 50 patients (Zero group). The zero-fluoroscopy approach exhibited significantly shorter procedural time (59.6 ± 10.7 min vs. 74.6 ± 13.2 min, p < 0.0001), attributed to a reduced access time (17 [16; 20] min vs. 31 [23; 34.5] min, p < 0.001). Comparable results were found for the number of RF applications, total ablation energy, and left atrial dwelling time. In the Zero group, all procedures were achieved without fluoroscopy, resulting in significantly lower fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p < 0.0001) and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p < 0.0001). The acute success rate was 100%, with no major complications. Zero-fluoroscopy PVI is feasible, safe, and associated with shorter procedure times compared to the standard approach, even in cases without prior experience in zero-fluoroscopy PVI.

Which neonates should have a pre-operative echocardiography? Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom.

PURPOSE: The detection of congenital heart disease (CHD) before neonatal surgery is crucial for anaesthetic and perioperative management. There are no established criteria for pre-operative echocardiography in neonates. We aimed to survey current practice in the United Kingdom and evaluate the reliability of antenatal screening and postnatal clinical assessment in detecting CHD before surgery. METHOD: A 9-point questionnaire was sent to all paediatric surgical centres in the United Kingdom to assess their practice. Subsequently, a single-centre retrospective review of all neonatal surgery over 5 years (2015-2020) was conducted in our tertiary paediatric/neonatal hospital. Data included pre-operative clinical assessment, performance of chest radiograph and echocardiography. Indications for echocardiography were categorised and assessed using sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: All 26 paediatric surgical centres responded to our survey. 23/26 (88.5%) did not have established criteria or guidelines for pre-operative echocardiography. There was a large variation in which surgical conditions required a pre-operative scan and whether a normal clinical examination was considered sufficient to not require one. For the retrospective review, 454 patients were identified. There were 40 cases with CHDs (8.8%), 13 were classed as major or moderate. Indications for echocardiography were categorised into abnormal foetal cardiac screening, medical/surgical conditions associated with CHD and an abnormal cardiorespiratory examination. Sensitivity, specificity, positive predictive value and negative predictive value for major and moderate CHD were 46%, 99%, 67%, 98% for abnormal foetal screening, 46%, 97%, 35%, 98% for associated medical conditions, 62%, 66%, 6%, 98% for associated surgical conditions, and 100%, 66%, 9%, 100% for abnormal clinical examination. CONCLUSION: The use of pre-operative echocardiography in neonates is not standardised across the UK. The results from our cohort demonstrate that foetal echocardiography is not sufficient to capture all major and moderate CHDs, but the absence of abnormal clinical examination is highly reliable in ruling out them out. Specifying a list of medical/surgical of conditions associated with CHD warranting pre-operative echocardiography may improve yield, but this depends on the availability of resources and expertise.

Left atrial strain parameters to predicting elevated left atrial pressure in patients with atrial fibrillation.

OBJECTIVES: To assess the ability of left atrial (LA) strain parameters to discriminate patients with elevated left atrial pressure (LAP) from patients with atrial fibrillation (AF). METHODS AND RESULTS: A total of 142 patients with non-valvular AF who underwent first catheter ablation (CA) between November 2022 and November 2023 were enrolled in the study. Conventional and speckle-tracking echocardiography (STE) were performed in all patients within 24 h before CA, and LAP was invasively measured during the ablation procedure. According to mean LAP, the study population was classified into two groups of normal LAP (LAP < 15 mmHg, n = 101) and elevated LAP (LAP ≥ 15 mmHg, n = 41). Compared with the normal LAP group, elevated LAP group showed significantly reduced LA reservoir strain (LASr) [9.14 (7.97-11.80) vs. 20 (13.59-26.96), p < .001], and increased LA filling index [9.60 (7.15-12.20) vs. 3.72 (2.17-5.82), p < .001], LA stiffness index [1.13 (.82-1.46) vs. .47 (.30-.70), p < .001]. LASr, LA filling index and LA stiffness index were independent predictors of elevated LAP after adjusted by the type of AF, EDT, E/e', mitral E, and peak acceleration rate of mitral E velocity. The receiver-operating characteristic curve (ROC) analysis showed LA strain parameters (area under curve [AUC] .794-.819) could provide similar or greater diagnostic accuracy for elevated LAP, as compared to conventional echocardiographic parameters. Furthermore, the novel algorithms built by LASr, LA stiffness index, LA filling index, and left atrial emptying fraction (LAEF), was used to discriminate elevated LAP in AF with good accuracy (AUC .880, accuracy of 81.69%, sensitivity of 80.49%, and specificity of 82.18%), and much better than 2016 ASE/EACVI algorithms in AF. CONCLUSION: In patients with AF, LA strain parameters could be useful to predict elevated LAP and non-inferior to conventional echocardiographic parameters. Besides, the novel algorithm built by LA strain parameters combined with conventional parameters would improve the diagnostic efficiency.

Can Glypican-6 Levels Be Used to Determine Right Ventricular Remodeling After Non-ST Segment Elevation Myocardial Infarction?

OBJECTIVE: Myocardial infarction is associated with right ventricular (RV) remodeling. Glypican-6 (GPC6), a member of the membrane proteoglycan family, plays a significant role in cardiac remodeling. This study aims to determine if GPC6 can predict RV remodeling after percutaneous coronary intervention (PCI) in patients with non-ST segment elevation myocardial infarction (NSTEMI). METHODS: The study enrolled 164 consecutive patients with NSTEMI and controls. It compared baseline plasma GPC6 levels, echocardiography, and laboratory parameters between the RV remodeling and non-RV remodeling groups with NSTEMI. Echocardiographic data were measured at baseline and at six months. RESULTS: GPC6 levels were higher in the NSTEMI group 11.06 ng/mL (4.61-18.17) vs. 5.98 ng/mL (3.81-9.83) compared to the control group in the initial phase. RV remodeling, defined as a ≥ 20% increase in RV end-diastolic area (RV EDA), was observed in 23 patients (30%). After six months, RV EDA increased significantly from baseline 18.68 ± 1.20 cm2 vs. 24.91 ± 1.08 cm2, P < 0.001. GPC6 was a significant independent predictor of RV remodeling (hazard ratio [HR]: 1.546, 95% confidence interval [CI]: 1.056-2.245, P < 0.001). Receiver operating characteristic curve (ROC) analyses showed that GPC6 values > 15.5 ng/mL (area under the curve [AUC] = 0.828, sensitivity: 70%, specificity: 74%, P < 0.001) were strong predictors of RV remodeling. CONCLUSION: NSTEMI patients should be closely monitored for RV remodeling. GPC6 appears useful in detecting RV remodeling following NSTEMI in patients undergoing PCI.

Effect of Exercise on Left Atrium Mechanics in Mild Mitral Stenosis.

OBJECTIVE: A significant number of individuals with mild mitral stenosis (MS) experience exertional symptoms that are disproportionate to the hemodynamic severity of their condition. This study aims to determine whether exercise-induced left atrial (LA) dysfunction occurs in these patients and whether it is related to the development of symptoms. METHODS: In this observational study, we recruited 46 patients with mild MS. Echocardiographic measurements were initially taken at rest, followed by a maximal exercise stress test. Patients were then returned to the echocardiography laboratory for post-exercise measurements. RESULTS: Our study cohort exhibited considerably higher left atrial volume index (LAVI) values (mean: 40.52 ± 18.27) compared to those of a healthy population. Furthermore, the LA reservoir strain (mean: 17.1 ± 8.33) was reduced relative to reference values. Following exercise, there was no change in the LA reservoir strain. However, trans-mitral pressure gradients and systolic pulmonary artery pressures increased. The post-exercise mean trans-mitral gradient was identified as the sole predictor of symptom development in patients with mild MS. CONCLUSION: The LA reservoir strain is already reduced in individuals with mild MS, and exercise does not lead to further decline in LA reservoir function in these cases. To our knowledge, this study is the first to explore the effects of exercise on LA mechanics in MS.

Comparison of Beating-Heart Technique Versus Aortic Cross-Clamping in Tricuspid Valve Surgery.

OBJECTIVE: Tricuspid valve surgery can be performed on a beating heart or on an arrested heart. We aimed to compare the outcomes of tricuspid valve surgery using these two different approaches. METHODS: Between January 2015 and February 2020, 204 patients who underwent tricuspid valve surgery along with concomitant cardiac surgical procedures were included in the study. Techniques of cross-clamping and beating-heart tricuspid surgery were applied to 103 and 101 patients, respectively. Concomitant valvular and/or coronary interventions were performed under cross clamping in both groups. Results from the preoperative period, immediate postoperative period, and six-month postoperative interval were compared between the groups. RESULTS: There were no differences in demographic characteristics or preoperative grades of tricuspid valve regurgitation between the groups. Duration of mechanical ventilation, and stays in the intensive care unit and hospital were significantly shorter in patients operated on using the beating-heart technique. Additionally, re-exploration surgery and mortality rates were significantly lower in the beating-heart group. Postoperative six-month echocardiography findings related to tricuspid valve regurgitation, maximum and minimum gradients of the tricuspid valve, and pulmonary arterial pressure were also lower in the beating-heart group. CONCLUSION: Beating-heart tricuspid valve surgery may be preferable to the cross-clamping technique to avoid clamp-induced ischemia, which can lead to worsened postoperative outcomes.

Left Ventricular Hypertrophy Findings on Electrocardiogram Predict Impaired Left Atrial Functions.

OBJECTIVE: Electrocardiographic left ventricular hypertrophy (ECG LVH) holds significant clinical importance in cardiovascular disease. Pathological processes that lead to left ventricular hypertrophy (LVH) also induce remodeling and impair left atrial (LA) function. Atrial function can be assessed using speckle-tracking echocardiography. This study investigates the potential impact of ECG LVH on LA strain. METHODS: A total of 62 individuals diagnosed with LVH, based on the echocardiographic left ventricular mass index, were included. ECG LVH was assessed using established protocols: the Sokolow-Lyon voltage criteria (SV1 + RV5/RV6 > 35 mm), Cornell voltage criteria (RaVL + SV3 > 28 mm for men and > 20 mm for women), and the Cornell product criteria [(SV3 + RaVL + (for women 8 mm)] x QRS duration > 2440 mm x ms). Participants were categorized into two groups based on the presence or absence of ECG LVH. The relationship between LA strain measures and ECG characteristics was explored. RESULTS: The study population had a median age of 58.3 ± 10.1 years, with 40.3% being female, 91.9% hypertensive, and 35.5% diabetic. Nineteen patients (30.6%) were identified with ECG LVH based on Sokolow-Lyon voltage, Cornell voltage, or Cornell product criteria. These patients exhibited significantly reduced LA reservoir, conduit, and contraction strains (P < 0.001). Statistically significant correlations were observed between all three phases of LA strain measures and Sokolow-Lyon voltage (reservoir r = -0.389, P < 0.01; conduit r = -0.273, P < 0.05; contraction r = -0.359, P < 0.01), Cornell voltage (reservoir r = -0.49, P < 0.001; conduit r = -0.432, P < 0.001; contraction r = -0.339, P < 0.01), and Cornell product (reservoir r = -0.471, P < 0.001; conduit r = -0.387, P < 0.01; contraction r = -0.362, P < 0.01). CONCLUSION: ECG LVH is associated with impaired LA strain, validating its use as an effective tool for predicting LA dysfunction.

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.

Increasing region of interest width reduces neonatal circumferential strain.

OBJECTIVE: There is growing interest in speckle tracking echocardiography-derived strain as a measure of left ventricular function in neonates. However, knowledge gaps remain regarding the effect of image acquisition and processing parameters on circumferential strain measurements. The aim of this study was to evaluate the effect of using different region of interest (ROI) widths on speckle tracking derived circumferential strain in healthy neonates. METHODS: Thirty healthy-term-born neonates were examined with speckle-tracking echocardiography in the short-axis view. Circumferential strain values were acquired and compared using two different ROI widths. Furthermore, strain values in the different vendor-defined wall layers were also compared. RESULTS: Increasing ROI width led to a decrease in global circumferential strain (GCS) in the midwall and epicardial layers, the respective decreases in strain being -23.4 ± .6% to -22.0 ± 1.1%, p < .0001 and 18.5 ± 1.7% to -15.6 ± 2.0%, p < .0001. Segmental analyses were consistent with these results, apart from two segments in the midwall. There was no statistically significant effect on strain for the endocardial layer. A gradient was seen where strain increased from the epicardial to endocardial layers. CONCLUSION: Increasing ROI width led to a decrease in GCS in the midwall and epicardium. There is an increase in circumferential strain when moving from the epicardial toward the endocardial layer. Clinicians wishing to implement circumferential strain into their practice should consider ROI width variation as a potential confounder in their measurements.