Atrial fibrillation (AF) is among the most prevalent forms of clinically significant arrhythmia, and stroke incidence is among the most serious AF-related complications, causing high rates of morbidity and mortality among affected patients. The European Society of Cardiology guidelines recommend a thromboembolic event risk assessment based on the CHA2DS2-VASC score. However, stroke also occurs in some patients with a low CHA2DS2-VASC score. Therefore, it is necessary to improve thromboembolic risk stratification in AF patients. The left atrial appendage (LAA) is considered to be the most frequent site of thrombus formation. Approximately 47% of thrombi in valvular AF and 91% of thrombi in nonvalvular AF are localized in the LAA. Therefore, identification or exclusion of LAA thrombi is critical in many clinical situations. It is essential to assess LAA morphology and function using imaging modalities (particularly echocardiography) before, during, and after interventional procedures such as AF ablation and LAA occlusion. This review article describes the anatomical, physiological, and LAA assessment in daily practice.
Defining normative aortic echocardiographic values in each geographical district is crucial as aortic valve area (AVA) may vary across races, genders, and ages. Notably, variations in normal values can have implications for clinical decision-making, and available data on the Middle East population is also scarce. We sought to establish normal ranges for aortic valve echocardiographic parameters in the Iranian population and assess the effect of age, gender, weight, height, BMI, BSA, and blood pressure on them.
Our data were provided from the web-based echocardiographic data registry of Imam Khomeini Hospital Complex (IKHC). A total of 3251 healthy subjects older than 18 years old without any valvular stenosis were included in our study.
AVA's normal range was estimated at 1.92–4.52 and 1.67–3.80 cm2 in men and women, respectively. The annulus, AVA, AV VTI, and LVOT VTI were significantly larger in males, and this association remained significant after indexing AVA for weight, height, BMI, and BSA. Also, smaller AVA was associated with lower height, weight, BMI, and BSA in both men and women. Obese and hypertensive subjects had significantly larger AVA and annulus diameters.
Our study provided region-specific normal reference values for AV echocardiographic parameters and compared them across genders, ages, BMI, and blood pressure groups in the Iranian population.
Two-dimensional phase-contrast magnetic resonance imaging (2D flow MRI) and its multidimensional alternatives, 4D and 5D flow MRI, measure blood flow in the heart and great vessels. While 2D flow MRI is the standard technique, it has limitations regarding need for precise image plane prescribing and long scan time. In contrast, 4D and 5D flow MRI acquire 3D volumes, enabling retrospective assessment of all vessels. This review evaluates these three techniques for quantification of blood flow of the aortic and pulmonary valves in congenital heart disease.
A systematic literature search was conducted in August 2024 using the PUBMED database, including articles comparing 2D, 4D, and 5D flow MRI.
Fifteen articles comparing 2D and 4D, one comparing 2D and 5D and three articles comparing 4D and 5D flow MRI were included. No study compared all three techniques. 2D, 4D and 5D flow MRI demonstrated a good agreement for flow quantification. 4D flow MRI, however, tends to present a better accuracy and internal consistency than 2D flow MRI for determination of peak velocities and flow in stenotic lesions, particularly when comparing velocities to echocardiography. 4D and 5D flow MRI are associated with shorter scan times than 2D flow MRI.
4D and 5D flow MRI appear to offer promising alternatives to 2D flow MRI with the advantage of reduced scan times. Larger and prospective studies including echocardiography are needed to evaluate the potential of 4D and 5D to replace 2D flow MRI for flow quantification and peak velocity determination.
As right heart catheterization (RHC) is invasive and not always accessible, this study developed a noninvasive model (P-echo) to predict shunt closure feasibility in adult congenital heart disease (ACHD) patients with post-tricuspid valve shunt defects (PTD), specifically isolated ventricular septal defects (VSD) and patent ductus arteriosus (PDA).
A retrospective analysis of 1474 VSD or PDA patients from 2012 to 2022 was conducted. Echocardiographic parameters were assessed, and key variables identified via LASSO regression. The P-echo model incorporated left to right velocity (LRv), right to left velocity (RLv), tricuspid regurgitation (TR), pulmonary artery diameter (PA), and RV/LV ratio. Its predictive performance was evaluated using ROC curve analysis.
The P-echo model demonstrated excellent predictive performance with AUC values of 0.975 (95% CI: 0.965–0.984) in the derivation set, 0.963 (95% CI: 0.937–0.989) in the validation set, and high accuracy in both PDA (AUC 0.975, 95% CI: 0.965–0.984) and VSD (AUC 0.958, 95% CI: 0.936–0.980) subsets. In the derivation set, the model categorized patients into low (9.1% closure rate), medium (70.9% closure rate), and high-risk groups (99.7% closure rate) for shunt closure feasibility. Calibration plots confirmed the model's accuracy. Decision curve analysis showed a higher net benefit across a range of threshold probabilities, indicating the clinical usefulness of the model.
The P-echo model is a robust and reliable tool for predicting the feasibility of shunt closure in patients with PTD, offering a noninvasive alternative to RHC. This model can guide clinical decision-making and support individualized treatment strategies in ACHD management.
We previously reported four patent foramen ovale (PFO) morphological types that influenced right-to-left shunt (RLS) grades. Herein, we aimed to study the relationship between PFO morphology and cryptogenic stroke (CS). We further developed a nomogram based on four PFO morphological types and functional parameters to guide clinicians in judging the risk of PFO-associated stroke.
This was a retrospective observational study involving adult patients with PFO between January 2020 and November 2022. Patients were divided into a PFO-associated stroke group (CS group) and a group without cryptogenic stroke (non-CS group). Four types of PFO and RLS grades were analyzed. Nomograms were made to predict PFO-associated stroke using multivariable logistic regression analysis. The discrimination performance of the model was internally validated and assessed using the receiver operating characteristic.
We enrolled 389 patients (male, 182 patients; female, 207 patients) with PFO, the mean age was 43.3 ± 8.1 years. The derivation cohort comprised 293 patients (CS group, 186 patients; non-CS group, 107 patients). The predictive nomogram comprised PFO morphological types, interatrial septum (IAS) mobility distance, septum primum thickness, PFO channel length at rest, and contrast-transthoracic echocardiography (c-TTE) RLS grade during the Valsalva maneuver. A validation cohort was established (CS group, 61 patients; non-CS group, 35 patients). The model area under the curve (AUC) was 0.891 (95% confidence interval = 0.855−0.928) in the derivation cohort and 0.935 (95% confidence interval = 0.885−0.986) in the validation cohort. Calibration curve analysis showed that the nomogram had a C-index of 0.891 in the derivation cohort and 0.935 in the validation cohort. The decision curve analysis (DCA) indicated that the nomogram had clinical applicability.
Adding four PFO morphological types improved the risk stratification capability for PFO-associated stroke. The nomogram can identify high or low-risk PFO individuals and select patients who will likely benefit from interventional device closure.
The study aimed to evaluate the changes of left ventricular diastolic function and the improvement of clinical symptoms in hypertrophic cardiomyopathy (HCM) patients with heart failure with preserved ejection fraction (HFpEF) after percutaneous intramyocardial septal radiofrequency ablation (PIMSRA).
This study enrolled 31 adult HCM patients with HFpEF who underwent PIMSRA treatment. Electrocardiogram, imaging, and blood biochemical examinations were performed on these patients during a 6-month follow-up.
Compared with the baseline, at 6 months after PIMSRA, patients showed significant reductions in peak left ventricular outflow tract pressure gradients (resting gradient: from a mean of 83.24 to 23.40 mmHg, p < 0.001; postexercise gradient: from a mean of 109.70 to 33.39 mmHg, p< 0.001). The interventricular septal thickness reduced from a mean of 22.90 to 17.48 mm, p < 0.001. The E/e’ decreased from a median of 18.67 to 11.54, p < 0.001. The 6-minute walk distance (6MWD) increased from a mean of 359.03 to 435.81 m, p < 0.001. The Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ OS) increased from a mean of 57.57 to 71.93, p < 0.001. The number of HFpEF patients diagnosed according to the European Society of Cardiology's Heart Failure Association HFA-PEFF score decreased from 31 to 23. None of the patients had new-onset bundle branch block or complete heart block after PIMSRA.
PIMSRA is a safe and effective treatment. It can improve left ventricular diastolic function and quality of life in HCM patients.
Diagnosing cardiac sarcoidosis (CS) is challenging due to the lack of a sensitive gold standard diagnostic test. Although advanced imaging techniques like cardiac magnetic resonance imaging (MRI) (cardiovascular magnetic resonance [CMR]) and fluorodeoxyglucose positron emission tomography (FDG-PET) CT are promising, they are limited by their availability and cost. Two-dimensional speckle-tracking echocardiography (2D-STE) is emerging as a valuable tool for the early detection of CS.
This single-center observational study assessed cardiac involvement and the utility of STE as a screening tool for diagnosing CS among newly diagnosed, histologically confirmed, treatment-naïve patients with systemic sarcoidosis in an Indian cohort.
The study included 48 newly diagnosed sarcoidosis patients with a median age of 42.5 years (interquartile range [IQR] 34–53.5), of whom 52.1% were female. FDG-PET CT findings suggested cardiac involvement in 21 patients, while CMR findings were positive in 11 patients. All patients had normal 12-lead ECGs and echocardiograms. Twenty-five patients met the HRS 2014 criteria for CS diagnosis. The median (IQR) left ventricular global longitudinal strain (LV GLS) was −15.4 (−16.2, −13.4) in the probable CS group and −17.9 (−19.4, −17.4) in the non-CS group. An LV GLS cutoff of >−17.3 showed a sensitivity of 80.00% and a specificity of 82.61% (p < 0.001, area under the curve [AUC] = 0.790) for CS diagnosis. A right ventricular global longitudinal strain (RV GLS) cutoff of >−21.4 showed a sensitivity of 68.00% and a specificity of 78.26% (p < 0.017, AUC = 0.692). They both have very high negative predictive value (98.7% and 97.9%) and thus useful for ruling out the cardiac involvement than confirming it.
STE effectively screens for cardiac involvement in sarcoidosis patients, ruling out CS diagnosis.
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