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The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

Background Stress echocardiography (SE) has been widely used in clinical practice for decades and recently has gained even more importance in diagnostic approach to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise test. We aimed to assess the feasibility of probe fixation for the use during exercise echocardiography. Methods 48 subjects (47 men, mean age 42±17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). We assessed semi-quantitatively the quality of acquired apical views at each stage using four-point grading system (0 = poor, 1 = suboptimal, 2 = acceptable, 3 = optimal). Results The mean time required for probe fixation was 9±2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. 25 patients probe repositioning during exercise (more often on treadmill). During peak exercise quality of images in all views declined, but it remained sufficient in 29 patients for diagnostic purposes. Thus, 76% of performed tests (60% for all study population) were of sufficient image quality. Conclusion Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. However the device is suitable almost exclusively for male patients. Moreover, in some patients it requires repositioning. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Purpose To assess the accuracy of an algorithm for automated measurement of the left ventricular ejection fraction (LVEF) available on handheld ultrasound device (HUD). Methods 112 patients admitted to the cardiology department, who were referred for the conventional echocardiographic examination, underwent additional assessment performed with HUD (Vscan Extend, GE Vingmed Ultrasound, Horten, Norway). In each case 4 – chamber apical view was obtained and LVEF was calculated by means of the LVivo software. Imaging quality was assessed in a 4-grade scale. Subsequently, during the examination performed with the use of the stationary echocardiograph the three-dimensional (3D) measurement of LVEF was recorded. Results Ultimately 96 (53 men, mean age 63 ± 11) patients were enrolled into the study group In the remaining 16 cases (14%) 3D image quality was not sufficient to allow the calculation of the LVEF. LVivo software was unsuccessful in calculating LVEF in all these 16 patients and in additional 20 patients, who remained in the study group due to satisfactory 3D image quality. The quality of images acquired with the use of HUD was assessed as optimal in 25 (26%) patients, good in 37 (39%), acceptable in 24 (25%), poor in 10 (10%). The average LVEF value was 46%±14 with the 3D LVQ measurements and 48%±14 using the LVivo software. The correlation coefficient between the LVEF values obtained with the two methods was r = 0,92; (P LVivo software EF assessment is based on a single apical view and for this reason we have assumed that the differences in EF can be larger in patients with regional wall motion abnormalities, in whom LVEF values derived from different apical views can significantly vary. For this reason the group of patients with history of myocardial infarction (40pts, 42%) was analysed separately and we found that the difference between LVivo and 3D LVEF was also not statistically significant (mean difference 6,1± 3,3%; P= 0,14). The correlation coefficient equalled r = 0,78; (P Conclusion The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality. Such expanded capabilities of HUDs can potentially lead to the overall improvements of the diagnostic accuracy of the ultrasonographic examinations, particularly when in hands of the non-expert echocardiographers.

Background An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique. Methods The study population comprised 122 patients (92 men, mean age 65±11 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2±2 days prior to surgery (TTE1), and 7±4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12±2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function (such as TAPSE, systolic velocity of tricuspid annulus (S'), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS), as well as a new parameter introduced by our team - RV shortening fraction (RV SF), calculated as the change in mid RV transverse diameter. Results Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S' and GLS; p Conclusion Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Grant Polish Cardiac Society

Purpose To investigate the relationship between right atrial deformation and the right ventricular size and function. Methods 94 patients with various cardiovascular pathologies have been included in the study group. All patients underwent transthoracic echocardiography with subsequent off-line analysis using speckle tracking technique and measurement of numerous right atrial deformation parameters, including peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS), as well as established indices of right ventricular size and function, including right ventricular basal diameter in apical four-chamber view (RVITd), tricuspid annular peak systolic excursion (TAPSE) and global longitudinal strain (GLS). Results There was a statistically significant weak correlation between RA strain (PACS and PALS) and RV parameters. RV-GLS showed significant correlation with PALS (r = -0,38; p = 0,0015) and PACS (r = - 0,30; p = 0,013). Similarly, TAPSE correlated with PALS and PACS (r = 0,34; p = 0,02) and (r = 0,23; p = 0,04) respectively. However, there was no correlation between right atrial function and RVIT. Conclusions Right atrial deformation parameters weakly correlate with right ventricular function indices and show no correlation with the size of the right ventricle.

Background Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV). Methods We enrolled 4,735 patients (age 63.6 ± 11.3 yrs, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (n=1,992 patients) and adenosine (n=18); ≤2.0 for exercise (n=2,087) or dobutamine (n=638). Results Force-based LVCR was obtained in all 4,735 pts. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57 % of patients with abnormal LVCR nevertheless showed increase in stroke volume. Conclusions Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Background An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique. Methods The study population comprised 105 patients (76 men, mean age 65 ± 16 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2 ± 2 days prior to surgery (TTE1) , and 7 ± 4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12 ± 2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function, such as TAPSE, systolic velocity of tricuspid annulus (S"), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS). Results Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S’ and GLS; p Conclusion Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. After 12 months, an improvement of the longitudinal function can be observed.

Objectives The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE). Background B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE. Methods The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up. Results According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction. Conclusions Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020 - The International Stress Echo Study [SE2020]; NCT03049995)

Background The differentiation between dilated cardiomyopathy (DCM) and systolic dysfunction caused by coronary artery disease (CAD) based on clinical and echocardiographic presentation can be difficult in some cases. Aim Our study aimed to define differences in myocardial function between patients with ischemic and nonischemic etiology of reduced left ventricular ejection fraction using 2D speckle tracking echocardiography (STE). Material and methods We retrospectively analyzed 90 patients (mean age 65 ± 11 years, 70% male) with de novo diagnosed reduced left ventricular ejection fraction (≤45% as determined by the transthoracic echocardiography), who were referred for coronary angiography to determine the presence of significant CAD. On the basis of coronary angiography results, patients were divided into two subgroups as follows: 45 subjects with significant CAD (group A) and 45 subjects without CAD (group B). Acquired transthoracic echocardiographic images were assessed off-line using 2DSTE. In each patient, we calculated arithmetic mean, median value, and standard deviation of regional longitudinal strain and strain rate of 18 left ventricular segments. Results Standard deviation of the regional peak early diastolic strain rate was significantly higher in group A than in group B (P = 0.01). The cutoff value with the highest diagnostic value was >0.37/s-its sensitivity and specificity for the diagnosis of CAD were 73% and 53%, respectively. The remaining parameters did not differ significantly between the study groups. Conclusions Patients with systolic dysfunction resulting from CAD have significantly more heterogeneous regional longitudinal early diastolic strain rate assessed by 2DSTE than patients with DCM.

INTRODUCTION MicroRNA (miRNAs) are noncoding RNAs involved in the regulation of gene expression. Certain miRNAs, especially miRNA-21 (miR-21), may be involved in lipid metabolism. OBJECTIVES The aim of the study was to evaluate the association between plasma free circulating miR-21 levels and lipid fractions: total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides (TG), as well as their atherogenic profile expressed as the ratio of individual lipid fractions (TC:LDL-C, TC:non-HDL-C, TG:HDL-C, and HDL-C:LDL-C) in patients with acute coronary syndromes without persistent ST -segment elevation (NSTE ACS). PATIENTS AND METHODS The study group consisted of 34 patients diagnosed with NSTE ACS on admission to the emergency department. Plasma miRNA levels were determined by real-time polymerase chain reaction and the ΔΔCt method. Serum lipid fractions were assessed after a minimum of 12-hour fasting during the first day of hospitalization. RESULTS MiR-21 levels showed a significant inverse correlation with TC (r = -0.5; P = 0.002), LDLC (r = -0.5; P = 0.001), and non-HDL-C (r = -0.6; P

PURPOSE The assessment of temporal changes in systolic and diastolic regional left ventricle function by two-dimensional speckle tracking echocardiography (STE) after successful reperfusion therapy of acute myocardial infarction (AMI). METHODS A total of 97 consecutive patients admitted with AMI and treated with successful percutaneous coronary intervention were included in this study. On days 1, 2, 3, 7, 30 and 180 following admission patients underwent transthoracic echocardiography with subsequent measurement of systolic longitudinal strain (SLS), systolic longitudinal strain rate (SRS) and early diastolic longitudinal strain rate (SRe) in left ventricular segments by speckle tracking technique. RESULTS The largest increase in regional SLS and SRS was observed between day 1 and 2. On days 3, 7, 30 and 180 further improvement was noticeable, but the changes were less significant. The highest prognostic value among STE parameters for predicting systolic function recovery after 6-month-long follow-up was achieved by measuring SLS on day 3 (area under the curve = 0·878). CONCLUSIONS The most of regional systolic function recovery occurs within the first 2 days. The recovery of regional diastolic function takes longer - the most significant part of improvement occurs within the first 7 days. STE parameters have prognostic value for predicting the improvement of systolic function after 180 days.

Objective The aim of the study was to investigate whether the deformation of left atrium (LA) measured by speckle-tracking analysis (STE) is associated with the presence of LA appendage thrombus (LAAT) during non-valvular atrial fibrillation (AF). Methods Eighty-seven patients (mean age 67 years, 59% men) were included to retrospective cross-sectional study. On top of standard echocardiography we assessed: LA longitudinal systolic strain (LS), systolic (LSSR) and early diastolic strain rate (LESR) in four-chamber and twochamber apical views. All patients underwent transesophageal echocardiography disclosing LAAT in 36 (41%) patients. Results Subgroups with and without thrombi did not differ with regard to clinical characteristics. Univariate factors associated with LAAT were as follows: CH2ADS2-VASc Score, left ventricular ejection fraction (LVEF), LV mass, and STE measurements. In a multivariate model only LVEF (p=0.002), LS (p=0.02), LESR (p=0.008), and LSSR (p=0.045) were independently associated with LAAT presence. Moreover, LVEF and LA STE measurements provided incremental value over the CH2ADS2-VASc Score. Conclusion Speckle-tracking TTE may be used to describe LA reservoir and conduit function during AF, allowing the identification of patients with higher risk of LAAT and providing incremental value over the CH2ADS2-VASc Score.

A 53-year-old patient, previously in good health condition, was admitted to the Cardiology Department with a history of chest pain and ECG abnormalities suggesting a recent myocardial infarction. Troponin level was not elevated, but the echocardiogram revealed a huge aneurysm with possible wall rupture and thrombus adjacent to the apex. The ejection fraction was very low, estimated for 23%. The magnetic resonance imaging confirmed the primary diagnosis of pseudoaneurysm. Treatment with ACE-i and diuretics was initiated, and the patient was discharged in stable condition. Subsequently, the case was discussed with cardiac surgeons: despite high risk, the patient was qualified for operation. The left ventricle was reconstructed with a bovine pericardial patch using the Menicanti method, and the patient recovered well. The control echocardiogram showed significant improvement of left ventricular contractility with ejection fraction of 35%.

Background: Three-dimensional (3D) fusion of morphological data obtained by coronary computed tomography angiography (CCTA) with functional data from resting and stress echocardiography could potentially provide additional information compared to examination results analyzed separately and increase the diagnostic and prognostic value of non-invasive imaging in patients with suspected coronary artery disease (CAD). Using vendor-independent software developed in our institution, we aimed to assess the feasibility and reproducibility of 3D fusion of morphological CCTA data with echocardiographic data regarding regional myocardial function. Methods: Thirty patients with suspected CAD underwent CCTA and resting transthoracic echocardiography. From CCTA we obtained 3D reconstructions of coronary arteries and left ventricle (LV). Offline speckle-tracking analysis of the echocardiographic images provided parametric maps depicting myocardial longitudinal strain in 17 segments of the LV. Using our software, 3 independent investigators fused echocardiographic maps with CCTA reconstruc­tions in all patients. Based on the obtained fused models, each segment of the LV was assigned to one of the major coronary artery branches. Results: Mean time necessary for data fusion was 65 ± 7 s. Complete agreement between independent investigators in assignment of LV segments to coronary branches was obtained in 94% of the segments. The average coefficient of agreement (kappa) between the investigators was 0.950 and the intra-class correlation coefficient was 0.9329 (95% CI 0.9227–0.9420). Conclusions: Three-dimensional fusion of morphological CCTA data with quantitative echocardiographic data on regional myocardial function is feasible and allows highly repro­ducible assignment of myocardial segments to coronary artery branches.