Background: Although Doppler evaluation using a multiplanar method is recommended to assess the severity of aortic stenosis (AS) with transthoracic echocardiography, evidence on the diagnostic significance of a non-apical method is limited. This study aimed to compare the use of the apical window (AW) with use of the right parasternal window (RW) method to evaluate AS severity and to examine the diagnostic significance of performing the RW method in addition to the AW method during the evaluation. Methods: This retrospective observational study included 287 consecutive patients (mean age: 79 ± 10 years; women, 56%) with severe AS (aortic valve area [AVA] ≤1.0cm 2). The severity of AS according to the AW method and that according to the RW for all subjects were compared, and the significance of performing the RW method in addition to the AW method was examined. Furthermore, we compared the concordance group, in which the AW and RW methods indicated matching in severity, and the discordant group, in which the AW and RW methods did not indicate matching severity. Results: Peak velocity (PV), mean pressure gradient (PG), and AVA were not significantly different between the AW and RW methods. Performing the RW method in addition to the AW method significantly decreased the number of low PG AS cases (mean PG <40 mmHg) from 71.1% to 65.0% and it increased the number of very severe AS cases (PV ≥5m/s) from 8.7% to 14.5%. Although, there was no significant difference in the Doppler angle (DA) observed using the AW method for the discordant group and the concordant group, the DA observed using the RW method was significantly smaller in the discordant group (8.8±8.2, 16.3±12.3 °, p<0.01). In the receiver-operating characteristic analysis, with the RW method, a DA of 8° was the cutoff value for discrepancies between the two groups. Conclusions: By performing the RW method in addition to the AW method to determine AS severity, different severity is observed in approximately 10% of cases. These results suggest that AS severity may be underestimated by using the AW method alone.

Background Right ventricular dysfunction is a major cause of heart failure and mortality in end-stage renal disease patients. Scarce data is available regarding the comparison of echocardiographic right ventricular function in end-stage renal disease patients on hemodialysis (HD) and peritoneal dialysis (PD). The aim of the study was to evaluate the long-term impacts of different dialysis modalities on right ventricular function assessed by conventional echocardiography, in end-stage renal disease patients with preserved left ventricular function. Methods The study included 120 patients grouped as follows: PD(n=40), HD with arterio-venous fistula (n=40) and healthy control subjects (n=40). Conventional echocardiography was performed in all patients. A classification of right ventricular function was defined in HD patients by using tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index (RV-MPI), fractional area change (FAC) and tricuspid lateral annulus systolic velocity (Sa) values. Correlation analysis was performed by using right ventricular dysfunction score, clinical and echocardiographic parameters. Results The mean age of the study population was 51.9±13.1 years and 47.5% were females. TAPSE and Sa velocity were found to be significantly lower and RV-MPI was significantly higher in patients undergoing HD, compared with control and PD patients. Logistic regression analysis showed that HD treatment was an independent risk factor for developing right ventricular dysfunction. Conclusion RV function was impaired in patients undergoing HD compared with patients on PD.

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Prosthetic valve endocarditis with mechanical complications causing pulmonary edema is fatal, therefore it needs to be diagnosed early and should be treated surgically in emergency setting. Transesophageal echocardiogram is crucial for recognizing the mechanical complications, which can be encountered on daily practice, but the coexistence of complications occurring on different mechanism is rather uncommon. Herein, we report a 21-year-old gentleman presenting with acute heart failure, whose imaging tests showed a combination of dehiscence of mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm and hematoma causing right ventricular collapse.

Objective: To evaluate for cardiac involvement in recovered COVID-19 patients using cardiac magnetic resonance imaging (MRI). Methods: A total of 30 subjects recently recovered from COVID-19 and abnormal left ventricular global longitudinal strain were enrolled. Routine investigations, inflammatory markers and cardiac MRI were done at baseline with follow-up scan at 6 months in individuals with abnormal baseline scan. Additionally, 20 age-and sex-matched individuals were enrolled as healthy controls (HCs). Results: All 30 enrolled subjects were symptomatic during active COVID-19 disease and were categorized as mild: 11 (36.7%), moderate: 6 (20%) and severe: 13 (43.3%). Of the 30 patients, 16 (53.3%) had abnormal CMR findings. Myocardial edema was reported in 12 (40%) patients while 10 (33.3%) had LGE. No difference was observed in terms of conventional LV parameters however, COVID-19 recovered patients had significantly lower right ventricular (RV) ejection fraction, RV stroke volume and RV cardiac index compared to HCs. Follow-up scan was abnormal in 4/16 (25%) with LGE persisting in 3 patients. Myocardial T1 (1284 + 43.8 ms vs 1147.6 + 68.4 ms; P<0.0001) and T2 values (50.8+16.7 ms vs 42.6+3.6 ms; P=0.04) were significantly higher in post COVID-19 subjects compared to HCs. Similarly, T1 and T2 values of severe COVID-19 patients were significantly higher compared to mild and moderate cases. Conclusions: An abnormal CMR was seen in half of recovered patients with persistent abnormality in one-fourth at six months. Our study suggests a need for closer follow-up among recovered subjects in order to evaluate for long term cardiovascular sequalae.

【Abstract】Aim To construct a prediction model based on functional mitral regurgitation (FMR) in patients with paroxysmal atrial fibrillation (PAF) for predicting atrial fibrillation recurrence after the post-circular pulmonary vein radiofrequency ablation (CPVA). Methods We retrospectively analyzed 289 patients with PAF who underwent CPVA for the first time . The patients were randomly divided into modeling group and verification group at the ratio of 75:25. In the modeling group, the multivariate logistic regression was used to analyze and construct a prediction model for post-CPVA recurrence in PAF patients, which was then validated in the verification group. Results (1) After 3-6 months of follow-up, the patients were divided into sinus rhythm group (252 cases) and recurrence group (24 cases); (2) In the modeling group, the age, LAD(left atrial diameter) and degree of MR (mild, moderate, severe) were higher in recurrence group than that of the sinus rhythm group, and the left atrial appendage emptying velocity (LAAV) was lower in recurrence group (all P<0.05). (3) A model for predicting the recurrence of PAF after radiofrequency ablation was constructed in the modeling group. The equation was: Logit(P) = -3.253 + 0.092 × age + 1.263 × mild MR + 2.325 × moderate MR + 5.111 ×severe MR - 0.113 × LAAV. The area under the curve (AUC) of the model was 0.889 in modeling group and 0.866 in verification group, and the difference was not statistically significant ( P>0.05). Conclusion: The prediction model of atrial fibrillation (AF) recurrence after CPVA in PAF patients has good predictive efficacy, high specificity and accuracy.

57-years old man presented with exertional dyspnea. An early systolic murmur was heard over the aortic areas 2D and 3D Echocardiography revealed unicuspid , unicommissural aortic valve (UAV) with a characteristic “teardrop” lateral orifice (Figure A) and moderate valve stenosis (3D planimetered aortic valve area (AVA) is 1.1cm2) (Figure B) Continuous wave Doppler across aortic valve (AV) showed high peak and mean systolic gradients of 85 and 60mmHg respectively.(Figure C). 2D /3D Transesophageal Echocardiography (TOE) revealed a subaortic ridge attached to the posterior annulus (Arrow) (Figure D) Further En-face viewing of the aortic valve from the left ventricular outflow tract (LVOT) perspective showed a shelf-like ridge extending from the commissure to the cusp (Arrow) (Figure E) Zoomed mode of the aortic- LVOT junction confirmed the presence of the subaortic ridge seen attached to the posterior aortic annulus near the commissural opening (Figure F) The patient was referred for surgical consultation .. Unicupid aortic valve (UAV) is a rare congenital anomaly that has.2 subtypes ; unicomissural and acommissural subtypes. Both can present with variable degrees of the aortic stenosis (AS) and/or aortic valve regurgitation (AR).UAV has more early, accelerated and severe valvular degeneration in addition to smaller orifice in comparison with bicuspid and tricuspid aortic valve. Echocardiography is the gold standard for diagnosis and evaluation of the AV morphology and function and the associated disorders such as ventricular septal defect , aortopathy and subaortic obstruction.. Surgical aortic valve replacement (AVR) and repair of the associated anomalies are the most common treatment modality .

Objectives: Echocardiographic assessment of Left ventricular systolic function is traditionally being performed by estimation of fractional shortening and Ejection fraction. Speckle tracking echocardiography (STE) is a promising tool for assessment of myocardial function. The aim of this study is to evaluate the global longitudinal strain (GLS) using 2D-STE in healthy neonates to establish normal reference ranges. Method: it is a retrospective study through an analysis of transthoracic echocardiogram of normal healthy neonates. We enrolled all neonates in our institution from 1 st January 2021 to 28 th February 2021. 2-D STE was used to assess left ventricular global longitudinal strain from the apical views. Results: 185 neonates were enrolled. Mean value for left ventricle GLS (%) was -19.9 ± 1.2, GLS-derived ejection fraction (%) was 60.0 ± 2.7; while the left ventricle ejection fraction by biplane Simpson’s method (%) was 61.0 ± 3. There is a good positive correlation between the Left Ventricle EF by biplane Simpson’s method and EF by 2-D STE, which was statistically significant ( r = 0.294,  n = 102,  p=0.003). Apical 4-chamber longitudinal strain and strain derived EF is significantly correlated with GLS and bi-plan EF respectively. Conclusion: 2-STE is feasible technique for analyzing newborn myocardial systolic function. The normal range of GLS in neonates is not much different than reported for the pediatric. There is a good positive correlation between the Left Ventricle EF by 2-D STE and EF by biplane method.

Background Two-dimensional (2D) strain imaging has become an important tool in assessing subclinical myocardial dysfunction in children. However, there are no pediatric reference values for vendor independent strain software. The aim of this study was to estimate 2D strain values in a cohort of healthy children using Tomtec cardiac performance analysis (CPA), a vendor independent software. Methods Transthoracic echocardiograms of healthy pediatric outpatients (0-18yrs) were retrospectively analyzed from the Vanderbilt Pediatric Heart Institute using CPA. Cardiac assessment included global longitudinal strain (GLS), global longitudinal strain rate (GLSR), global circumferential strain (GCS), global circumferential strain rate (GCSR). Mean strain values with standard deviation (SD) are reported. The Wilcoxon rank sum test, linear regression and one-way analysis of variance were used to assess differences among the various groups. Results Among 142 children analyzed, 79 (56%) were male, and the median age was 5.5 (range, 0-18) years. The mean (SD) strain values were GLS -19.3 ± 3.4, GLSR -1.1 ± 0.22; GCS -24.7 ± 4.3, GCSR -1.5 ± 0.28. Age accounted for <8% of variation in GLS, GCS and GSCR. However, for GLSR, there was a statistically significant difference between younger and older age groups with higher GLSR in the younger age group. Age accounted for ~25% of variation in GLSR (R 2 = 0.25, P < 0.001). There were no significant differences in strain based on sex. Conclusion We report normal reference values in healthy children by age for strain using CPA. These values are necessary for the interpretation of 2D strain imaging for both clinical care and research.

We read with great interest the article by Vetrugno et al. who reported the important association of preoperative diastolic dysfunction (DD) and early liver allograft dysfunction.[1](#ref-0001) We salute the authors on this detailed and important investigation, and would like to highlight several points. First, the authors provide the cohort analysis of donors’ and recipients’ demographic variables (Table 1, Ref[1](#ref-0001)), however statistical comparative analysis of the three study groups and these variables is absent. Moreover, additional, important demographic variables (e.g., ethnicity, presence of trans jugular intrahepatic portosystemic shunt; hepato-pulmonary syndrome, porto-pulmonary hypertension, pretransplant hospitalization or vasopressors; QT interval) and intraoperative variables (e.g., hemoglobin, coagulative and thromboelastographic parameters, arrhythmias, immunosuppression, and post-reperfusion syndrome and vasopressors) were not included in the groups’ analysis (Table 4, Ref[1](#ref-0001)). These parameters are predictive of postoperative major adverse cardiac events and unfavorable transplant outcomes.[2,3](#ref-0002) Lastly, an association does not imply causation,[4](#ref-0004) and both DD and early graft dysfunction may have an independent, common origin like cirrhotic cardiomyopathy.[5](#ref-0005) An adjustment for cofounders is, therefore, mandatory; regrettably, the omission of a multivariable analysis from the study obfuscates the interpretation of the observed association. Presumably, DD results in early allograft rejection and dysfunction via the attendant elevated pro-inflammatory cytokines, or increased venous pressure and hepatic allograft congestion.[6](#ref-0006) Postoperative cardiac variables (e.g., troponins, sono- and electrocardiography, venous and pulmonary pressures) and allograft biopsies were not reported in the study, but may direct clinicians to mitigating interventions to improve outcomes in liver allograft recipients with DD.

Abstract Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia following coronary artery bypass grafting (CABG). We hypothesized that measures of left atrial (LA) function would be useful in predicting AF in patients undergoing CABG. Methods and Results In the study, 611 patients were included after CABG. All patients had echocardiograms performed preoperatively and LA functional measurements were assessed. These measurements were LA maximum volume index (LAVmax), LA minimum volume index (LAVmin) and LA emptying fraction (LAEF). The endpoint was AF occurring >14 days after surgery. During the follow-up period of a median of 3.7 years, 52 (9%) developed AF. The mean age was 67 years, 84% were male and the average left ventricle ejection fraction was 50 %. No differences were observed between the patients developing AF and those who did not develop AF. No functional LA measurements were significant predictors of AF in the whole CABG population. However, in patients with normal-sized LA (n=532, events: 49), both LAEF and LAVmin were univariable predictors of AF. When the functional measurements were adjusted for the CHADS 2 score, both LAVmin (HR=1.07 (1.01-1.13), p=0.014 ) and LAEF (HR: 1.02 (1.00-1.03, p= 0.023)), remained significant predictors. Conclusion No echocardiographic measurements were significant predictors of AF after CABG. In patients with a normal LA size, LAVmin as well as LAEF were significant predictors of AF. Keywords: atrial fibrillation; cardiac surgery; left atrium; echocardiography

Background: Tako-tsubo syndrome (TTS) in its most typical form shares common features with anterior ST segment elevation myocardial infarction (AMI) during acute presentation. Differential diagnosis between the two conditions is often challenging especially if ST segment elevation is associated with extensive apical akinesis. Methods: we sought to systematically analyze ECG and echocardiographic parameters including LV longitudinal strain and two new indexes: the inferior-apex ratio (IAR) and the inferior-lateral-apex ratio (ILAR), to assess if ventricular involvement may be different in TTS and AMI. Results: A retrospective cohort study was conducted with 2 groups: patients with TTS (n=22) and patients with extensive anterior STEMI (n=22). Lack of ST elevation in V1 was associated with TTS with sensitivity and specificity of 86%, positive and negative predictive value of 86%. Longitudinal strain in mid inferior and mid inferior-lateral segments were more compromised in TTS: - 4.3±6.4% and -5.4± 5.4% in TTS vs -10.2±5.5% and -9.9 ±4.9% in AMI, respectively (P<0.01 for all). By multivariate analysis, both longitudinal strain values, inferior-apical ratio (IAR) <1 and inferior-lateral-apical ratio (ILAR) <1 were independently associated with diagnosis of TTS during acute phase. Conclusions: our results suggest that impaired contractility extending beyond apex to mid inferior and inferior-lateral walls can be easily assessed by IAR and ILAR, and these indexes facilitate non-invasive differentiation of TTS from extensive anterior STEMI.

Objective: To study the value of fetal epicardial fat thickness (EFT) in gestational diabetes mellitus in the third trimester of pregnancy and its relationship with clinical parameters and perinatal outcomes. Methods: A total of 80 participants, including 40 with diagnosed GDM and 40 healthy pregnant women, were included in the study. Demographic data were obtained from medical records. Sonographic examinations were performed, such as amniotic fluid value, fetal biometric measurements, and Doppler parameters of the umbilical artery. Fetal EFT values were measured at the free wall of the right ventricle using a reference line with echocardiographic methods. Correlation tests were performed to evaluate the relationship between fetal EFT and clinical and perinatal parameters. P < 0.05 were interpreted as statistically significant. Results: The fetal EFT value was statistically higher in the GDM group than in the control group (p:0.000). Spearman correlation tests revealed statistically significant but weak positive correlations between fetal EFT value, 1-hour 100-gr OGTT, birth weight, and BMI (r: 0.198, p:0.047; r:0.395, p:0.012; r:0.360, p:0.042, respectively). The optimal fetal EFT threshold for predicting GDM disease was found as 1.55 mm, with a specificity of 74.4% and sensitivity of 75.0%. Statistically significant differences between the two groups in umbilical artery Doppler resistance index (RI), pulsatility index (PI), and systolic/diastolic ratio (S/D) were not found (p:0.337; p:0.503; p:0.155;). BMI and amniotic fluid volume were higher in the GDM group compared to the control group (p:0.009; p:0.000). Conclusion: This study demonstrated that increased fetal EFT may occur as a reflection of changes in glucose metabolism in intrauterine life. Future studies with larger series, including the study of neonatal metabolic parameters, will contribute to the understanding of the importance of fetal EFT in determining the metabolic status of the fetus.

Background: Three-dimensional echocardiography (3DE) is an emerging method for volumetric cardiac measurements; however, few vendor-neutral analysis packages exist. Ventripoint Medical System Plus (VMS3.0+) proprietary software utilizes a validated MRI database of normal ventricular and atrial morphologies to calculate chamber volumes. This study aimed to compare left ventricular (LV) and atrial (LA) volumes obtained using VMS3.0+ to Tomtec echocardiography analysis software. Methods: Healthy controls (n=98) aged 0 to 18 years were prospectively recruited and 3D DICOM datasets focused on the LV and LA acquired. LV and LA volumes and ejection fractions were measured using TomTec Image Arena 3D LV analysis package and using VMS3.0+. Pearson correlation coefficients, Bland-Altman’s plots and intraclass coefficients (ICC) were calculated, along with analysis time. Results: There was a very good correlation between VMS and Tomtec LV systolic (r 2 = 0.88, ICC 0.89 [95% CI 0.81,0.94]), and diastolic (r 2 = 0.88, ICC 0.90 [95% CI 0.77,0.95]) volumes, and between VMS and Tomtec LA diastolic (r 2 =0.75, ICC 0.89 [95% CI 0.81,0.93]) and systolic (r 2 =0.88, ICC 0.91 [95% CI 0.78,0.96]) volumes on linear regression models. Natural log transformations eliminated heteroscedasticity, and power transformations provided best fit. The time (mins) to analyze volumes using VMS were less than using Tomtec (LV VMS 2.3±0.5, Tomtec 3.3±0.8, p<0.001; LA: VMS 1.9±0.4, Tomtec 3.4±1.0, p<0.001). Conclusions: There was very good correlation between knowledge-based (VMS3.0+) and 3D (Tomtec) algorithms when measuring 3D echocardiography derived LA and LV volumes in pediatric patients. VMS was slightly faster than Tomtec in analyzing volumetric measurements.

Herein we present a case of concomitant congenital anomalies with an iatrogenic defect. The female patient underwent a percutaneous mitral balloon valvuloplasty due to rheumatic mitral stenosis. Unfortunately, an iatrogenic atrial septal defect (ASD) occurred and also, partial anomalous pulmonary venous return was observed at post-procedure evaluation. The patient had severe symptoms and the right heart chambers were dilated on imaging. But perhaps, the most crucial point was that the patient was planning a pregnancy. After a difficult and patient-involved decision process, the patient underwent to successful robotic surgery for iatrogenic ASD and partial anomalous pulmonary venous return. After operation, the patient was asymptomatic and right heart chambers normalized.

COVID-19 related MIS-C (Multisystem inflammatory syndrome in children) can present with cardiovascular complications like shock, arrhythmias, pericardial effusion, and coronary artery dilatation. The majority of MIS-C associated coronary artery abnormalities are dilation or small aneurysms which are transient and resolve in a few weeks[[1, 2]](#ref-0001). We present here a case of a 3-month-old child who was noted to have giant aneurysms of her coronary arteries (LAD and RCA) twenty-six days after testing positive for COVID-19. She was treated with IVIG, infliximab, and glucocorticoids along with aspirin, clopidogrel and enoxaparin. She did not show any signs of coronary ischemia or cardiac dysfunction but continued to have persistent giant coronary artery aneurysms involving the LAD (z-score ~35) and RCA (z-score ~30) [Fig. 1]. This study emphasizes the importance of early detection and aggressive management of MIS-C to prevent potentially life-threatening consequences.

Objectives In stress echocardiography (SE), dipyridamole (DIP) and dynamic stress (ExSE) are reported as safer than dobutamine stress (DSE). We investigated whether commonly used stressors cause myocardial injury, measured by high sensitivity troponin T (hsTnT). Methods 135 patients (DSE n=46, ExsE n=46, DIP n=43) with negative SE were studied. Exclusion criteria were known ischemic heart disease (IHD), baseline wall motion abnormalities, left ventricle systolic dysfunction/regional wall motion abnormalities, septum/posterior wall ≥13 mm, diabetes, baseline hsTnT level ≥14 ng/L, baseline blood pressure ≥160/100 mmHg, peak pulmonary pressure ≥45mmHg, eGFR <1mL/s/1.73m2, more than mild to moderate valvular disease and dobutamine side effects. HsTnT was measured before and 180 minutes after the test. Results All patients had low pre-test probability of IHD. HsTnT increased in DSE, less so in ExSE, and unchanged in DIP group [9.4 (1.5–58.6), 1.1 (-0.9–15.7), -0.1 (-1.4–2.1) ng/L, p<0.001]. In DSE, hsTnT change was associated with peak dobutamine dose (r=0.30, p= 0.045), test length (r=0.43, p=0.003) and atropine use (p<0001). In ExSE, hsTnT rise was more likely in females (p=0.012) and elderly (>65 years) (r=0.32, p=0.03), no association was found between atropine use (p=0.786) or test length and hsTnT rise (r=0.10, p=0.530). Conclusions DSE is associated with myocardial injury in patients with negative SE, no injury was observed in DIP and only mild one in ExSE. Whether myocardial injury is causative of the higher reported adverse event rates in DSE remains to be determined.

Aim: We aimed to examine fetal cardiac output (CO) in patients who recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Materials: This prospective study included 48 pregnant women recovered from SARS-CoV-2 infection and 50 control cases. SARS-CoV-2 infection was diagnosed by polymerase chain reaction (PCR) test in patients. Fetal echocardiographic evaluations were performed at 24-37 weeks of gestation in pregnant women who recovered from the infection and control group. Results: The median value of ultrasound evaluation was 34 (2.6) weeks of gestation in the recovery from the SARS-CoV-2 infection (RSI) group, and 32 (7.6) weeks in the control group (p=0.565). Left cardiac output (LCO) z score was significantly lower in the RSI group than the control group (p=0,041). LCO and combine cardiac output (CCO) z score were significantly lower in the severe disease group than mild, moderate disease groups, and controls (p=0,019 and p=0,013). CCO (mL/min/kg) was decreased in the severe disease group when compared with control and mild disease groups (p=0,044). Fetal distress, preterm delivery rate, and neonatal intensive care unit (NICU) admission were found to be higher in the severe disease group compared to the control group (p=0,010, p=0,009, and p<0,001 respectively). Conclusion: In the present study, fetal cardiac output in pregnant women with recovery from SARS-CoV-2 infection was found significantly decreased, especially in whom had severe diseases. Placental dysfunction and inflammatory cytokines might cause fetal cardiac changes. Further studies could be clarified on the impact of SARS-CoV-2 infection on fetal cardiac function.