Traditionally, echocardiography is used for volumetric measurements to aid in assessment of cardiac function. Multiple echocardiographic-based assessment techniques have been developed, such as Doppler ultrasound and deformation imaging (e.g., peak global longitudinal strain (GLS)), which have shown to be clinically relevant. Volumetric changes across the cardiac cycle can be related to deformation, resulting in the Ventricular Strain-Volume/Area Loop. These Loops allow assessment of the dynamic relationship between longitudinal strain change and volumetric change across both systole and diastole. This integrated approach to both systolic and diastolic function assessment may offer additional information in conjunction with traditional, static, measures of cardiac function or structure. The aim of this review is to summarize our current understanding of the Ventricular Strain-Volume/Area Loop, describe how acute and chronic exposure to hemodynamic stimuli alter Loop characteristics, and, finally, to outline the potential clinical value of these Loops in patients with cardiovascular disease. In summary, several studies observed Loop changes in different hemodynamic loading conditions and various (patho)physiological conditions. The diagnostic and prognostic value, and physiological interpretation remain largely unclear and have been addressed only to a limited extent.
Background: Outpatient care for patients with heart valve disease (HVD) is best provided by valve clinics delivered by specialists. Modern day practice in the United Kingdom (UK) is currently poorly understood and has not been evaluated for nearly a decade. Furthermore, the COVID 19 pandemic changed the management of many chronic diseases, and how this has impacted patients with heart valve disease is unclear.
Methods: A British Heart Valve Society survey was sent to 161 hospitals throughout the UK.
Results: There was a general valve clinic in 46 of the 68 hospitals (68%), in 19 of 23 Heart Centres (83%) and 29 of 45 DGHs (64%). Across all settings, 3824 new patients and 17,980 follow up patients were seen in valve clinics per annum. The mean number of patients per hospital were 197 (median 150, range 48-550) for new patients and 532 (median 400, range 150-2000) for follow up. On the day echocardiography was available in 55% of valve clinics. In patients with severe HVD, serum brain natriuretic peptide (BNP) was measured routinely in 39% of clinics and exercise testing routinely performed in 49% of clinics. A patient helpline was available in 27% of clinics. 78% of centres with a valve clinic had a valve multidisciplinary team meeting (MDT). 45% centres had an MDT co-ordinator and MDT outcomes were recorded on a database in 64%. COVID-19 had a major impact on valve services in 54 (95%) hospitals.
Conclusions: There has been an increase in the number of valve clinics since 2015 from 21 to 68% but the penetration is still well short of the expected 100%, meaning that valve clinics only serve a small proportion of patients requiring surveillance for HVD. COVID-19 had a major impact on the care of patients with HVD in the majority of UK centres surveyed.
Background: Machine learning (ML) algorithms can accurately estimate left ventricular ejection fraction (LVEF) from echocardiography, but their performance on cardiac point-of-care ultrasound (POCUS) is not well understood.
Objectives: We evaluate the performance of an ML model for estimation of LVEF on cardiac POCUS compared with Level III echocardiographers' interpretation and formal echo reported LVEF.
Methods: Clinicians at a tertiary care heart failure clinic prospectively scanned 138 participants using hand-carried devices. Video data were analyzed offline by an ML model for LVEF. We compared the ML model's performance with Level III echocardiographers' interpretation and echo reported LVEF.
Results: There were 138 participants scanned, yielding 1257 videos. The ML model generated LVEF predictions on 341 videos. We observed a good intraclass correlation (ICC) between the ML model's predictions and the reference standards (ICC = 0.77-0.84). When comparing LVEF estimates for randomized single POCUS videos, the ICC between the ML model and Level III echocardiographers' estimates was 0.772, and it was 0.778 for videos where quantitative LVEF was feasible. When the Level III echocardiographer reviewed all POCUS videos for a participant, the ICC improved to 0.794 and 0.843 when only accounting for studies that could be segmented. The ML model's LVEF estimates also correlated well with LVEF derived from formal echocardiogram reports (ICC = 0.798).
Conclusion: Our results suggest that clinician-driven cardiac POCUS produces ML model LVEF estimates that correlate well with expert interpretation and echo reported LVEF.
Background: Work-related musculoskeletal pain (WRMSP) is increasingly recognised in cardiac ultrasound practice. WRMSP can impact workforce health, productivity and sustainability. We sought to investigate the prevalence, characteristics and clinical impact of WRMSP.
Methods: Prospective electronic survey of 157 echocardiographers in 10 institutions. Data acquired on demographics, experience, working environment/pattern, WRMSP location, severity and pattern, the impact on professional, personal life and career.
Results: 129/157 (82%) echocardiographers completed the survey, of whom 109 (85%) reported WRMSP and 55 (43%) reported work taking longer due to WRMSP. 40/129 (31%) required time off work. 78/109 (60%) reported sleep disturbance with 26/78 (33%) of moderate or severe severity. 56/129 (45%) required medical evaluation of their WRMSP and 25/129 (19%) received a formal diagnosis of musculoskeletal injury. Those with 11+ years of experience were significantly more likely to receive a formal diagnosis of WRMSP (p = 0.002) and require medication (p = 0.006) compared to those with 10 years or less experience.
Conclusion: WRMSP is very common amongst echocardiographers, with a fifth having a related musculoskeletal injury. WRMSP has considerable on impact on personal, social and work-related activities. Strategies to reduce the burden of WRMSP are urgently required to ensure sustainability of the workforce and patient access to imaging.
Introduction: Athletic training can result in electrical and structural changes of the right ventricle that may mimic phenotypical features of arrhythmogenic right ventricular cardiomyopathy (ARVC), such as T-wave inversion and right heart dilatation. An erroneous interpretation may have consequences ranging from false reassurance in an athlete vulnerable to cardiac arrhythmias, to unnecessary sports restriction in a healthy individual. The primary aim of this study was to define normal RV dimension reference ranges for academy adolescent footballers of different ethnicities. Secondary aims include analysis of potential overlap between this adolescent group with ARVC criteria and comparison with normal adult ranges.
Results: Electrocardiographic (ECG) and echocardiographic data of 1087 academy male footballers aged between 13 and 18 years old (mean age 16.0 ± 0.5 years), attending mandatory cardiac screening were analysed. Ethnicity was categorised as white (n = 826), black (African/Caribbean; n = 166) and mixed-race (one parent white and one parent black; n = 95). Arrhythmogenic right ventricular cardiomyopathy major criteria for T-wave inversion was seen in 3.3% of the cohort. This was more prevalent in black footballers (12%) when compared to mixed race footballers (6.3%) or white footballers (1%), P < 0.05. Up to 59% of the cohort exceeded adult reference ranges for some of the right ventricular parameters, although values were similar to those seen in adult footballers. There were no differences in right ventricular dimensions between ethnicities. In particular, the right ventricular outflow tract diameter would fulfil major criteria for ARVC dimension in 12% of footballers. Overall, 0.2% of the cohort would fulfil diagnosis for 'definite' arrhythmogenic right ventricular cardiomyopathy and 2.2% would fulfil diagnosis for 'borderline' arrhythmogenic right ventricular cardiomyopathy for RV dimensions and ECG changes. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P < 0.05. Among athletes meeting definite or borderline arrhythmogenic right ventricular cardiomyopathy criteria, no cardiomyopathy was identified after comprehensive clinical assessment, including with cardiac magnetic resonance imaging, exercise testing, ambulatory electrocardiograms and familial evaluation.
Conclusion: Right heart sizes in excess of accepted adult ranges occurred in as many as one in two adolescent footballers. Structural adaptations in conjunction with anterior T-wave inversion may raise concern for ARVC, highlighting the need for evaluation in expert settings.
Transthoracic echocardiography is an essential and widely available diagnostic tool for assessing individuals reporting cardiovascular symptoms, monitoring those with established cardiac conditions and for preparticipation screening of athletes. While its use is well-defined in hospital and clinic settings, echocardiography is increasingly being utilised in the community, including in the rapidly expanding sub-speciality of sports cardiology. There is, however, a knowledge and practical gap in the challenging area of the assessment of coronary artery anomalies, which is an important cause of sudden cardiac death, often in asymptomatic athletic individuals. To address this, we present a step-by-step guide to facilitate the recognition and assessment of anomalous coronary arteries using transthoracic echocardiography at the bedside; whilst recognising the importance of performing dedicated cross-sectional imaging, specifically coronary computed tomography (CTCA) where clinically indicated on a case-by-case basis. This guide is intended to be useful for echocardiographers and physicians in their routine clinical practice whilst recognising that echocardiography remains a highly skill-dependent technique that relies on expertise at the bedside.
Background: The athlete's heart (AH) defines the phenotypical changes that occur in response to chronic exercise training. Echocardiographic assessment of the AH is used to calculate LV mass (LVM) and determine chamber geometry. This is, however, interpreted using standard linear (ratiometric) scaling to body surface area (BSA) whereas allometric scaling is now widely recommended. This study (1) determined whether ratiometric scaling of LVM to BSA (LVMiratio) provides a size-independent index in young and veteran athletes of mixed and endurance sports (MES), and (2) calculated size-independent beta exponents for allometrically derived (LVMiallo) to BSA and (3) describes the physiological range of LVMiallo and the classifications of LV geometry.
Methods: 1373 MES athletes consisting of young (< 35 years old) (males n = 699 and females n = 127) and veteran (> 35 years old) (males n = 327 and females n = 220) were included in the study. LVMiratio was calculated as per standard scaling and sex-specific LVMiallo were derived from the population. Cut-offs were defined and geometry was classified according to the new exponents and relative wall thickness.
Results: LVMiratio did not produce a size independent index. When tested across the age range the following indexes LVMi/BSA0.7663 and LVMi/BSA0.52, for males and females respectively, were size independent (r = 0.012; P = 0.7 and r = 0.003; P = 0.920). Physiological cut-offs for LVMiallo were 135 g/(m2)0.7663 in male athletes and 121 g/(m2)0.52 in female athletes. Concentric remodelling / hypertrophy was present in 3% and 0% of young male and female athletes and 24% and 17% of veteran male and female athletes, respectively. Eccentric hypertrophy was observed in 8% and 6% of young male and female athletes and 9% and 11% of veteran male and female athletes, respectively.
Conclusion: In a large cohort of young and veteran male and female MES athletes, LVMiratio to BSA is not size independent. Sex-specific LVMiallo to BSA with LVMi/BSA0.77 and LVMi/BSA0.52 for male and female athletes respectively can be applied across the age-range. Population-based cut-offs of LVMiallo provided a physiological range demonstrating a predominance for normal geometry in all athlete groups with a greater percentage of concentric remodelling/hypertrophy occurring in veteran male and female athletes.
Background: Ultrasound enhancing agents (UEAs) are an invaluable adjunct to stress and transthoracic echocardiography (STE) to improve left ventricular visualization. Despite multiple single center studies evaluating UEA use, investigation into the rates, sources of variation, and outcomes of UEA use on a national level in the United States (US) has been limited by lack of validation of UEA codes for claims analyses.
Methods: We conducted a retrospective cross-sectional study, 2019-2022, using linked multicenter electronic medical record (EMR) data from > 30 health systems linked to all-payor claims data representing > 90% of the US population. Individuals receiving STE in both EMR and claims data on the same day during the study window were included. UEA receipt as identified by presence of a Current Procedural Terminology (CPT) or National Drug Code (NDC) for UEA use within 1-day of the index STE event. We evaluated the performance of claims to identify UEA use, using EMR data as the gold standard, stratified by inpatient and outpatient status.
Results: Amongst 54,525 individuals receiving STE in both EMR and claims data, 12,853 (23.6%) had a UEA claim in EMR, 10,461 (19.2%) had a UEA claim in claims, and 9140 (16.8%) had a UEA claim in both within the 1-day window. The sensitivity, specificity, accuracy, positive, and negative predictive values for UEA claims were 71.1%, 96.8%, 90.8%, 87.4%. and 91.6% respectively. However, amongst inpatients, the sensitivity of UEA claims was substantially lower (6.8%) compared to outpatients (79.7%).
Conclusions: While the overall accuracy of claims to identify UEA use was high, there was substantial under-capture of UEA use by claims amongst inpatients. These results call into question published rates of UEA use amongst inpatients in studies using administrative claims, and highlight ongoing need to improve inpatient coding for UEA use.
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