Background Device-related thrombosis (DRT) is a common finding after left atrial appendage closure (LAAC) and is associated with worse outcomes. As women are underrepresented in clinical studies, further understanding of sex differences in DRT patients is warranted. Methods and Results This sub-analysis from the EUROC-DRT-registry compromises 176 patients with diagnosis of DRT after LAAC. Women, who accounted for 34.7% (61/176) of patients, were older (78.0±6.7 vs. 74.9±9.1 years, p=0.06) with lower rates of comorbidities. While DRT were detected significantly later in women (173±267 vs. 127±192 days, p=0.01), anticoagulation therapy was escalated similarly, mainly with initiation of novel oral anticoagulant (NOAC), vitamin K antagonist (VKA) or heparin. DRT resolution was achieved in 67.5% (27/40) of women and in 75.0% (54/72) of men (p=0.40). In the remaining cases, an intensification/switch of anticoagulation was conducted in 50% (9/18) of men and in 41.7% (5/12) of women. Final resolution was achieved in 72.5% (29/40) cases in women, and in 81.9% (59/72) cases in men (p=0.24). Women were followed-up for a similar time as men (779±520 vs. 908±687 days, p=0.51). Kaplan-Meier analysis revealed no difference in mortality rates in women (Hazard Ratio [HR]: 1.73, 95%-Confidence interval [95%-CI]: 0.68-4.37, p=0.25) and no differences in stroke (HR: 0.83, 95%-CI: 0.30-2.32, p=0.72) within two years after LAAC. Conclusion Evaluation of risk factors and outcome revealed no differences between men and women, with DRT in women being diagnosed significantly later. Women should be monitored closely to assess for DRT formation/resolution. Treatment strategies appear to be equally effective.

Background Prenatal echocardiographic assessment of fetal cardiac function has become increasingly important. Fetal two-dimensional speckle-tracking echocardiography (2D-STE) allows the determination of global and segmental functional cardiac parameters. Prenatal diagnostics is relying increasingly on artificial intelligence, whose algorithms transform the way clinicians use ultrasound in their daily workflow. The purpose of this study was to demonstrate the feasibility of whether less experienced operators can handle and might benefit from an automated tool of 2D-STE in the clinical routine. Methods A total of 136 unselected, normal, singleton, second- and third-trimester fetuses with normofrequent heart rates were examined by targeted ultrasound. 2D-STE was performed separately by beginner and expert semiautomatically using a GE Voluson E10 (FetalHQ®, GE Healthcare, Chicago, IL, USA). Several fetal cardiac parameters were calculated (end-diastolic diameter (ED), sphericity index (SI), global longitudinal strain (EndoGLS), fractional shortening (FS)) and assigned to gestational age (GA). Bland-Altman plots were used to test agreement between both operators. Results The mean maternal age was 33 years, and the mean maternal body mass index prior to pregnancy was 24.78 kg/m 2. The GA ranged from 16.4 to 32.0 weeks (average 22.9 weeks). Averaged endoGLS value of the beginner was -18.57 % ± 6.59 percentage points (pp) for the right and -19.58 % ± 5.63 pp for the left ventricle, that of the expert -14.33 % ± 4.88 pp and -16.37 % ± 5.42 pp. With increasing GA, right ventricular endoGLS decreased slightly while the left ventricular were almost constant. The statistical analysis for endoGLS showed a Bland-Altman-Bias of -4.24 pp ± 8.06 pp for the right and -3.21 pp ± 7.11 pp for the left ventricle. The Bland-Altman-Bias of the ED in both ventricles in all analyzed segments ranged from -0.49 mm ± 1.54 mm to -0.10 mm ± 1.28 mm, that for FS from -0.33 pp ± 11.82 pp to 3.91 pp ± 15.56 pp and that for SI from -0.38 ± 0.68 to -0.15 ± 0.45. Conclusions Between both operators, our data indicated that 2D-STE analysis showed excellent agreement for cardiac morphometry parameters (ED and SI), and good agreement for cardiac function parameters (EndoGLS and FS). Due to its complexity, the application of fetal 2D-STE remains the domain of scientific-academic perinatal ultrasound and should be placed preferably in the hands of skilled operators. At present, from our perspective, an implementation into clinical practice ‘on-the-fly’ cannot be recommended.

Background: This study aimed to compare patients with migraine and embolic stroke of undetermined source (ESUS) with known patent foramen ovale (PFO) in terms of echocardiographic and clinical features. Methods: In this observational single-center study, we obtained 2-dimensional (2D) and color Doppler images using parasternal short axis (PSAX), apical 4-chamber (A4C), and subcostal 4-chamber (SC4C) transthoracic echocardiography (TTE) views for patients with Migraine and ESUS. In cases where a PFO was suspected, patients underwent transthoracic contrast echocardiography and transesophageal echocardiography (TEE). We compared the anatomical and functional high-risk characteristics of PFO, as assessed by TEE and the RoPe score, in both patient groups. Results: This research involved a cohort of 720 individuals with ages ranging from 18 to 60, and 73.2% of the participants were female. Among the participants, 43.5% had Migraine, and 56.5% had ESUS. The most common comorbidity was diabetes (26.1%). PFO characteristics were measured, and high-velocity shunting through the interatrial septum was observed in 35.5% of patients. ESUS patients had a higher median age, with a similar gender distribution. ESUS patients had higher rates of diabetes and hypertension, while active smoking was more common in Migraine patients. Basic echocardiographic parameters were similar, except for higher pulmonary artery systolic pressure in ESUS. In the ESUS group, as compared to the migraine group, there was a more substantial occurrence of large microbubble passage through the interatrial septum, and the PFO showed increased length, while the PFO width remained similar. The RoPe and High-risk PFO scores were similar between the groups. Conclusions: ESUS patients were older with higher rates of diabetes and hypertension, while Migraine patients had a higher prevalence of active smoking. ESUS patients showed elevated pulmonary artery pressure, increased large microbubble crossings through the interatrial septum, and longer PFO lengths.

Background: The prevalence of hypertrophic cardiomyopathy (HCM) can be silent and can present with sudden death as the first manifestation of this disease. The goal of this study was to evaluate any association between reported physical symptoms with the presence of suspected HCM. Method: The Anthony Bates Foundation has been performing screening echocardiography across the United States for the prevention of sudden death since 2001. A total of 4,120 subjects between the ages of 6 and 79 underwent echocardiographic screening. We evaluated any association between any symptoms and suspected HCM defined as any left ventricular wall thickness ≥ 15 mm. Results: The total prevalence of suspected HCM in the entire study population was 1.1%. The presence of physical symptoms were not associated with HCM (chest pain in 4.3% of participant with HCM vs. 9.9% of the control, p=0.19, palpitation in 4.3% of participant with HCM vs. 7.3% of the control., p=0.41, shortness of breath in 6.4% of participant with HCM vs. 11.7% of the control., p=0.26, lightheadedness in 4.3% of participant with HCM vs. 13.1% of the control., p=0.07, ankle swelling in 2.1% of participant with HCM vs. 4.0% of the control., p=0.52, dizziness in 8.5% of participant with HCM vs. 12.2% of the control., p=0.44). Conclusion: Echocardiographic presence of suspected HCM is not associated with a higher prevalence of physical symptoms in the participants undergoing screening echocardiography. This finding confirmed that HCM can be asymptomatic in many patients and a questionnaire cannot distinguish the HCM population from a control group.

Dobutamine stress echocardiography (DSE) is a test recommended for diagnosing coronary artery disease (CAD), which can also assess its severity. MAPSE (M-mode-derived long axis, mitral annular plane systolic excursion) can be used to measure the longitudinal shortening of the Left Ventricle (LV) which plays a major role in the pumping function of the cardiac muscle. For detecting early abnormalities, this parameter appears to be much more sensitive than global EF. Objective: In order to determine whether Delta change MAPSE in Dobutamine stress Echocardiography predicts ischemic heart disease and whether it correlates with coronary artery disease severity in patients with ischemic heart disease. Patients and Methods: This study evaluated 60 patients between April 2020 and July 2021, 30 of whom were ischemic (ischemic group) and 30 of whom were not (normal group). The MAPSE (septal, lateral, anterior, inferior anulus) is measured at each stress echo stage and the Delta MAPSE (Peak MAPSE – rest MAPSE) is calculated. Additionally, the EF is measured using modified Simpson’s method for each stage and the Delta EF (Peak EF – rest EF) is determined. These measurements are then compared between two groups. The severity of coronary artery disease is assessed using the Gensini score (GS). Results: Our study comprised a total of 60 patients, with an average age of 59.5 ± 7.3 years. The male gender was predominant, accounting for 74% of the participants. A notable disparity was observed between the two groups in terms of their diabetic history, which was statistically significant. Specifically, 53% of the patients had diabetes, whereas only 27% of the control group had the condition (p=0.035). There was a statistically significant difference observed between the two groups in terms of Delta MAPSE (p<0.0001). The Delta MAPSE in patients was recorded as -0.54 ± 0.3, whereas in the control groups it was 0.88 ± 0.7. Additionally, a statistically significant difference was found between the two groups based on Delta EF (p=0.012). The Delta EF in patients was measured as 1.5±5.6, while in the control groups, it was 4.8±3.9. There was a significant negative correlation observed between delta MAPSE and Gensini score in the patients’ group (P= 0.0085; r = - 0.47). Conversely, a negative correlation was also observed between delta EF and Gensini score in the patients’ group, although it was not statistically significant (P= .029; r = - 0.2). Conclusion: The reduced MAPSE in dobutamine stress echocardiography (DSE) is an efficient and straightforward quantitative echocardiographic technique that can accurately anticipate both the existence and the extent of coronary artery disease (CAD).

Background Mixed pulmonary disease with pulmonary regurgitation (PR) and stenosis (PS) in repaired tetralogy of Fallot (rTOF) can negatively impact ventricular health. Myocardial strain has been shown to be more sensitive at detecting occult ventricular dysfunction compared to right ventricular ejection fraction (RV EF). We hypothesize that rTOF patients with predominant PS will have lower RV global longitudinal strain (RVGLS) prior to and post-transcatheter pulmonary valve replacement (TPVR). Methods A retrospective cohort of rTOF patients who underwent cardiac magnetic resonance (CMR) and cardiac catheterization for right ventricular pressure (RVSP) measurement were analyzed at three time points: before valve implantation, at discharge and within 18 months post-TPVR. Patients were dichotomized into three groups based on RVSP: 0-49%, 50-74%, and >75%. RVGLS and left ventricular (LV) GLS by speckle tracking echocardiography (STE) were obtained from the apical 4-chamber using TomTec software (TOMTEC IS, Germany). Results Forty-eight patients were included. RV EF was not associated with a significant change in RV or LV GLS (p=0.7). RV GLS showed the greatest improvement immediately after valve implantation. Higher pre-implantation RVSP was found to correlate with worse strain (p=0.001). Overall, average RV strain magnitude was higher when pre-implantation RVSP was less than 50% and had greater improvement over the three time points. Higher post-implantation RVSP correlated with lower strain magnitude. Conclusion Patients with significant PS (>50%) may benefit from earlier PVR and not depend solely on RV size and EF. Myocardial strain may be a more sensitive marker of function; however, larger, prospective studies are needed.

Objective: Diagnosis of Aortic arch (AoA) anatomy is critical for planning cardiac surgery/intervention and in diagnosing associated congenital heart defects. AoA sidedness is traditionally diagnosed with echocardiography as being contralateral to the direction of the first brachiocephalic artery in suprasternal view, but this method can be challenged by numerous anatomic variants and clinical conditions. The objective of this study was to assess feasibility of trachea visualization with echocardiography in pediatric patients, and using this landmark to identify AoA sidedness and potential for double aortic arch (DAA). Methods: A prospective study was performed on patients <18 years old who were undergoing Chest CT/MRI to serve as gold standard for confirming AoA anatomy. A right-to-left echocardiographic sagittal sweep was performed from the suprasternal notch and used to categorize 1) Left AoA = right SVC-trachea-AoA, 2) Right AoA= SVC-AoA-trachea, 3) DAA = SVC-AoA-trachea-AoA. The proportion of successful sweeps and diagnostic accuracy were calculated. Results: 100 consecutive patients were scanned (44% female; median age of 8.8 yr, range 2d–17.9 yr; median BSA 1.14 m 2, range 0.2–2.7; right AOA in 4%). Diagnosis of AoA sidedness was possible in 97% (95% CI: 94–100%, p < 0.01) and correct in 100% when the trachea was seen. Conclusion: Tracheal imaging with echo is reliable, easy, and reproducible method in patients of various sizes and levels of acuity to define AoA sidedness.

Background: Transthoracic echocardiography (TTE) plays a key role in the initial work-up of myocarditis where the identification of pathologic structural and functional changes may assist in its diagnosis and management. The aim of this systematic review was to appraise the evidence for the utility of echocardiographic parameters of cardiac structure and function in the diagnosis of acute myocarditis in the adult population. Methods: A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing TTE parameters in adult patients with myocarditis (1995-2020; English only; PROSPERO registration CRD42021243598). Data for a range of structural and functional TTE parameters were individually extracted and those with low heterogeneity were then meta-analysed using a random-effects model for overall effect size, and assessed through standardized mean difference (SMD). Results: Available data from up to six included studies revealed that myocarditis can be reliably differentiated from healthy controls using echocardiographic measures of left ventricular (LV) size and systolic function, in particular LV end-diastolic diameter, LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS) (p≤0.01 for all). LV-GLS demonstrated the highest overall effect size, followed by LVEF and LVEDD (SMD: |0.46-1.98|). Two studies also demonstrated that impairment in LV-GLS was associated with adverse cardiovascular outcomes in this population, irrespective of LVEF. Conclusions: LV-GLS demonstrated the greatest overall effect size and therefore ability to differentiate myocarditis populations from healthy controls. GLS was also shown to be a predictor of adverse cardiovascular outcomes, in this population.

Objective To explore the value of speckle tracking echocardiography (STE) with low dose dobutamine stress echocardiography (LDDSE) for evaluation of viable myocardium (VM) in the acute ST-elevation myocardial infarction (STEMI) patients with or without type 2 diabetes mellitus (DM). Methods Eighty-five hospitalized patients with regional wall motion abnormalities (RWMA) according to routine echocardiography in STEMI, thirty patients with type 2 DM. All of them were underwent STE associated with LDDSE (STE-LDDSE) prior to coronary angiography and percutaneous coronary intervention (PCI). Every segment image was acquired and evaluated by wall-motion analysis. The images of STE-LDDSE were analyzed quantitatively for peak-systolic strain (S) and strain rate (Sr), the short axis of radial strain (RS), radial strain rate (RSr), circumferential strain (CS), circumferential strain rate (CSr) and the long axis of longitudinal strain (LS), longitudinal strain rate (LSr) by using the QLAB software. All patients underwent PCI within one week after completing STE-LDDSE examination, and echocardiograms were reviewed at 1, 3, and 6 months after surgery. Results A total of 183 regional wall motion abnormalities (RWMA) were detected in the DM group, of which 117 (63.93%) segments were viable myocardium; 357 RWMA were detected in non DM patients, of which 248 (69.47%) segments of viable myocardium were detected by echocardiography. The sensitivity, accuracy, and specificity of STE-LDDSE in detecting viable myocardium in DM group were 70.94%、77.45%、87.88% ; 92.31%、72.73% and 85.25% for LS and LSr. In the non DM group, the sensitivity, specificity, and accuracy of LS and LSr were 68.95%、92.66%、76.19% ; 77.42%、88.07% and 80.67%, respectively. Further parallel diagnostic tests were conducted on LS and LSr parameters. The sensitivity, specificity, and accuracy of detecting viable myocardium in the DM and non DM groups were 84.62%、45.45%、70.49%, 66.53%、63.30% and 65.55%, respectively, at rest; They were 84.62%、45.45%、70.49%, 66.53%、63.30% and 65.55%, respectively, during low dose dobutamine stress. Conclusion STE-LDDSE has a high value of detecting VM. Parallel diagnostic test for LS and LSr is the best choice in detecting VM in the patients with STEMI and is more sensitive for the patients with type 2 DM. It will be more effectively to guide the further treatment and to evaluate the prognosis of the STEMI patients.

Objectives: Congenital ventricular outpouching (CVO) is a rare cardiac malformation that can manifest as congenital ventricular aneurysm (CVA) and/or congenital ventricular diverticula (CVD). In this study, we describe the prenatal features and postnatal follow-up of 27 cases of CVO. Methods: The clinical data of 27 patients with CVO who attended Sir Run Run Shaw Hospital Affiliated to the Medical College of Zhejiang University (Zhejiang Province, China) and Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University (Zhejiang Province, China) from April 2013 to October 2022 were retrospectively analyzed. The patients were also followed up by telephone. The prenatal characteristics and postnatal outcomes of the patients with CVO were evaluated. Results: CVO was detected in 26 cases prenatally,, 14 (51.85%) were diagnosed with CVA, 9 (33.33%) were diagnosed with CVD, 3 (11.11%) were equivocal for CVA/CVD, and 1 (3.70%) was detected with CVA postnatally. Six patients underwent follow-up fetal echocardiography approximately 4 weeks after the initial echocardiography examination, and a significant difference in CVO size was observed between the two examinations ( P = 0.02). Eight patients (29.63%) demonstrated cardiovascular dysfunction, and the median CVO size in fetuses with and without cardiovascular dysfunction was 205 (range: 169–396) mm 2 and 124 (range: 92–154.5) mm 2, respectively ( P = 0.01). Eight patients (29.63%) had cardiac/extracardiac defects. Thirteen patients were live born, 12 were terminated pregnancies, and 2 were lost to follow-up. The postpartum size of the CVOs remained stable in six patients, decreased in two patients, dissolved in three patients, and were surgically removed in two patients. With the exception of one patient with CVA complicated with complex congenital cardiac malformation who underwent surgical treatment after birth and who had postoperative left ventricular dysfunction (Case 1), the prognosis of all of the patients was good. Conclusion: Most cases of fetal CVO have typical echocardiographic manifestations of CVA or CVD, while some cases manifest as a mixture of the two. The size of fetal CVO can increase with the increase in gestational age. The occurrence of cardiovascular dysfunction is related to the CVO size. Prenatal echocardiography should examine changes in CVOs and the occurrence of cardiovascular dysfunction. In general, the postpartum prognosis of fetal CVO is good.

Introduction An arteriovenous fistula (AVF) in patients with end-stage kidney disease (ESKD) can influence flow states. We sought to evaluate if assessment of aortic stenosis (AS) by transthoracic echocardiographic (TTE) differs in the presence of AVF compared to other dialysis accesses in patients on dialysis. Methods We identified consecutive ESKD patients on dialysis and concomitant AS from a single center between January 2000 and March 2021. We analyzed TTE parameters of AS severity (velocities, gradients, aortic valve area [AVA]) and hemodynamics (cardiac output [CO], valvuloarterial impedance [Zva]) and compared AS parameters in patients with AVF versus other dialysis access. Results The cohort included 94 patients with co-prevalent ESKD and AS; mean age 66 years, 71% male; 43% Black, 24% severe AS. Dialysis access: 53% AVF, 47% others. In the overall cohort, no significant differences were noted between AVF vs. non-AVF in AVA/CO/Zva, but with notable subgroup differences. In mild AS, CO was significantly higher in AVF vs. non-AVF (6.3 vs. 5.2 L/min; p=0.04). In severe AS, Zva was higher in the AVF vs. non-AVF (4.6 vs. 3.6 mmHg/ml/m 2). With increasing AS severity in the AVF group, CO decreased, coupled with increase in Zva, likely counterbalancing the net hemodynamic impact of the AVF. Conclusion Among ESKD patients with AS, TTE parameters of flow states and AS severity differed in those with AVF versus other dialysis accesses and varied with progression in severity of AS. Future longitudinal assessment of hemodynamic parameters in a larger cohort of co-prevalent ESRD and AS would be valuable.

Background: The need for echocardiograms among patients with long COVID is debatable. Our aim was to evaluate the prevalence of left ventricular (LV) dysfunction and identify predictors. Methods: We conducted a cross-sectional study and included all consecutive patients enrolled in our post-COVID clinic. We included patients who had an echocardiogram and had no previous known heart disease. We defined LV dysfunction as a low ejection fraction or grade II to grade III diastolic dysfunction on an echocardiogram with evidence of elevated filling pressures. We calculated the prevalence of heart disease and predictors of heart disease using logistic regression. Results: We included 217 post-COVID patients enrolled in the clinic. The prevalence of LV dysfunction is 24%;95% CI 18-30. Predictors of heart disease include older age and a previous history of hypertension and diabetes or having a intermediate or high ASCVD score. Patients with low ASCVD score did not have low ejection fraction on the screening echocardiograms. Conclusion: Our study found a considerable number of patients with LV dysfunction. Older patients with cardiovascular risk factors are at risk of long COVID associated heart disease.

Background: Atrial cardiopathy is a proposed mechanism of embolic stroke of undetermined source (ESUS). Left atrial (LA) strain may identify early atrial cardiopathy prior to structural changes. We aim to study the associations between LA strain, ESUS, and atrial fibrillation (AF) detection in ESUS. Methods: The study population included patients with ESUS and non-cardioembolic (NCE) stroke presenting to statewide stroke center between January 2016 and June 2017 who underwent transthoracic echocardiography. Speckle tracking echocardiography (STE) was used to measure the 3 phases of LA strain (reservoir, conduit, and contractile). Binary logistic regression analysis was performed to determine the associations between LA strain and stroke subtype (ESUS vs. NCE) as well as follow-up detection of AF in ESUS patients. Results: We identified 656 patients, 307 with ESUS and 349 with NCE. In binary logistic regression, the lowest tertiles of LA reservoir (adjusted OR 1.944, 95% CI 1.266-2.986, p = 0.002), contractile (aOR 1.568, 95% CI 1.035-2.374, p = 0.034), and conduit strain (aOR 2.288, 95% CI 1.448-3.613, p = 0.001) were more likely to be significantly associated with ESUS compared to NCE stroke. Among all ESUS patients, the lowest tertiles of LA reservoir strain (OR 2.534, 95% CI 1.029-6.236, p = 0.043), contractile strain (OR 2.828, 95% CI 1.158-6.903, p = 0.022), and conduit strain (OR 2.614, 95% CI 1.003-6.815, p = 0.049) were significantly associated with subsequent detection of AF. Conclusion: Reduced LA strain is associated with ESUS occurrence and AF detection in ESUS patients. Therefore, quantification of LA strain in ESUS patients may improve risk stratification and guide secondary prevention strategies.

Background: Previous case studies have reported reversal of acute renal failure after pericardiocentesis in pericardial effusion. This study examines the effects of pericardiocentesis on pre-procedural low cardiac output and acute renal dysfunction in patients with pericardial effusion. Methods: This is a retrospective study of 95 patients undergoing pericardiocentesis between 2015 and 2020. Pre- and post-procedure transthoracic echocardiograms (TTE) were reviewed for evidence of cardiac tamponade, resolution of pericardial effusion, and for estimation of right atrial (RA) pressure and cardiac output. Laboratory values were compared at presentation and post-procedure. Patients on active renal replacement therapy were excluded. Results: Ninety-five patients were included for analysis (mean age 62.2±17.8 years, 58% male). There was a significant increase in glomerular filtration rate pre- and post-procedure. Fifty-six patients (58.9%) had an improvement in glomerular filtration rate after pericardiocentesis (termed “responders”), and these patients had a lower pre-procedure glomerular filtration rate than “non-responders”. Forty-four patients (46.3%) had a greater than 10% improvement in glomerular filtration rate. There was a significant improvement in estimated cardiac output and right atrial pressure for patients in both groups. Patients who had an improvement in renal function had significantly lower pre-procedural diastolic blood pressure and mean arterial pressure. Conclusions: Pericardial drainage may improve effusion-mediated acute renal dysfunction by reducing right atrial pressure and thus systemic venous congestion, and by increasing forward stroke volume and perfusion pressure.

Coronary artery fistula is a rare cardiac disease which could be diagnosed by multiple imaging modalities and could be effectively treated by surgical or percutaneous closure. The patient is a 21 years old man initially presented with palpitation and paroxysmal atrial fibrillation. For further evaluation he underwent transthoracic echocardiography on which a mass like structure was found in right atrium. On transesophageal echocardiography this cystic structure was in continuation with dilated left circumflex coronary artery and based on data from both CT angiography and coronary angiography , coronary artery fistula with abnormal drainage right atrium was defined and percutaneous closure was proposed. Learning objective: As coronary artery fistula is a rare condition, making the acquaintance of its clinical presentation, the role of imaging modalities in diagnosis and therapeutic options is our concern. In this patient paroxysmal atrial fibrillation and then a cystic mass like structure in right atrium led us to the diagnosis in stepwise approach.

Introduction: Mitral annular disjunction (MAD) is a structural abnormality characterized by the systolic detachment of the posterior mitral annulus and the ventricular myocardium. It is usually observed coexistent with mitral valve prolapse(MVP) and associated with a mechanical dysfunction despite preserved electrical isolation function of the mitral annulus. Diagnosis depends on the detection of disjunction by imaging modalities as transthoracic echocardiography or cardiac magnetic resonance imaging (CMRI). This study aimed to evaluate left ventricular (LV) function using speckle tracking echocardiography in MVP patients with MAD. Methods: This study was designed as a prospective, single-center study including 103 patients with MVP and 40 age- and sex-matched control subjects. Transthoracic echocardiography and cardiac magnetic resonance imaging were performed to assess LV function and MAD presence. Results: MAD (+) MVP (n=34), MAD (-) MVP (n=69), and control (n=40) groups were enrolled in the study. Among the MVP patients, 34 (33%) had MAD. T negativity in the inferior leads on electrocardiography was more frequent in the MAD (+) group than in the MAD (-) patients (4.3% vs 20.6%, p=0.014). Mitral regurgitation degree, Pickelhaube sign (17.6% vs. 1.4%, p=0.005), and late gadolinium enhancement frequency (35.3% vs. 10.6%, p=0.002) were significantly higher in MAD (+) patients. MAD (+) patients had significantly impaired global longitudinal strain (GLS) -23.1±2.1 vs. -23.5±2.3, P<0.001), basal longitudinal strain (BLS) (-19.6±1.5 vs -20.5±1.9, P < 0.001), and Mid-Ventricular Longitudinal Strain(MVLS) (-22.2±1.7 vs -23.2±2.2, P<0.001) when compared to MAD (-) MVP patients, despite similar LV ejection fraction. All these values of MVP patients were also significantly lower than the control group. The mean MAD distance was 7.8 ± 3.2 mm in MAD (+) patients. Patients with 2 or more symptoms were higher in the MAD (+) group than in the MAD (-) group (4.3% vs 44.1%, P<0.001). Conclusion: This study demonstrated a significant decrease in longitudinal strain in MVP patients with MAD, indicating myocardial dysfunction. These findings suggest that MAD may contribute to LV dysfunction and highlight the importance of early detection in younger patients. Further research is needed to explore the functional implications and long-term outcomes of MAD.

Objective: To evaluate both short and mid-term effects of maternal COVID-19 on cardiac functions of fetuses and children. Methods: The present case-control study was conducted on 36 pregnant women who had COVID-19 infection in the second trimester of pregnancy and 30 pregnant women as healthy controls. Fetal, neonatal and infant cardiac functions were compared between the groups. Assessment of fetal cardiac functions were performed in the last trimester of the pregnancy at least 6 weeks after the recovery of infection. The first postnatal echo was performed within the first two weeks and the follow-up (second) echo was performed in the 6-8 weeks of life. Results: The demografic data were similar between groups. Interventricular septum and left ventricular posterior wall end-diastolic dimensions were significantly higher in the study group in both fetal, neonatal and infant periods. Impaired diastolic functions of right and left ventricles were detected and myocardial performance indexes with tissue doppler imaging of both lateral walls and septum were significantly higher than controls at all periods. Conclusion: Maternal COVID-19 seems to have a global impact on cardiac functions of babies in the short and mid-term periods after maternal recovery.

Half of patients with heart failure are presented with preserved ejection fraction (HFpEF). The pathophysiology of these patients is complex but increased left ventricular (LV) stiffness is proved to play a key role. However, the application of this parameter was limited since its measurements requires invasive catheterization. With advances in ultrasound technology, new advances have been achieved in the assessment of LV chamber or myocardial stiffness using noninvasive echocardiography. Therefore, this review was carried out to summarize the pathophysiological mechanisms, correlations with invasive LV stiffness constant, applications in different populations as well as the limitations of echocardiography-derived indices for assessment of both LV chamber and myocardial stiffness. LV chamber stiffness indices such as E/e’/LVEDV, E/SRe/LVEDV, and DPVQ were derived on the basis of the relationship between echocardiographic parameters of LVFP and LV size. However, all these methods are surrogate and lumped measurements, relying on E/e’ or E/SRe for evaluating LVFP. The limitations of E/e’ or E/SRe in assessment of LVFP may contribute to the moderate correlation between E/e’/LVEDV or E/SRe/LVEDV and LV stiffness constant. Even the best validated measurement (DPVQ) is considered unreliable in the individual patient. Compared to E/e’/LVEDV and E/SRe/LVEDV, I PVA/IA and F PVA/FA may display better performance in assessing LV chamber stiffness as evidenced by a higher correlation with LV stiffness constant. However, only one study has been conducted in the literature on the exploration and application of I PVA/I A and F PVA/F A, and its accuracy in assessing LV chamber stiffness remains to be confirmed. In terms of echocardiographic indices for LV myocardial stiffness evaluation, the parameters of EMI/DWS, iVP and SWI were proposed. Despite alteration of DWS and its predictive value of adverse outcomes in various populations have been widely validated, it was found that DWS may be better considered as an overall marker of cardiac function performance instead of pure myocardial stiffness. As for the iVP and SWI, the validities of these two indices in assessing LV myocardial stiffness have not been confirmed in invasive studies. More echocardiographic indices with higher sensitivities and specificities warrant to be further uncovered to evaluate LV stiffness.