Echocardiographic assessment of aortic regurgitation: a narrative review.

Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.

Predictors of in-hospital mortality in critically ill patients with COVID-19: a large dual tertiary centre study.

OBJECTIVES: The aim of this study was to investigate the relationship of echocardiographic parameters, laboratory findings and clinical characteristics with in-hospital mortality in adult patients with COVID-19 admitted to the intensive care units (ICU) in two large collaborating tertiary UK centres. DESIGN: Observational retrospective study. SETTING: The study was conducted in patients admitted to the ICU in two large tertiary centres in London, UK. PARTICIPANTS: Inclusion criteria were: (1) patients admitted to the ICU with a COVID-19 diagnosis over a period of 16 weeks. and (2) underwent a transthoracic echocardiogram on the first day of ICU admission as clinically indicated.No exclusion criteria applied.Three hundred patients were enrolled and completed the follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome measure in this study was in-hospital mortality in patients admitted to the ICU with COVID-19 infection. RESULTS: Older age (HR: 1.027, 95% CI 1.007 to 1.047; p=0.008), left ventricular (LV) ejection fraction<35% (HR: 5.908, 95% CI 2.609 to 13.376; p<0.001), and peak C reactive protein (CRP) (HR: 1.002, 95% CI 1.001 to 1.004, p=0.001) were independently correlated with mortality in a multivariable Cox regression model. Following multiple imputation of variables with more than 5% missing values, random forest analysis was applied to the imputed data. Right ventricular (RV) basal diameter (RVD1), RV mid-cavity diameter (RVD2), tricuspid annular plane systolic excursion, RV systolic pressure, hypertension, RV dysfunction, troponin level on admission, peak CRP, creatinine level on ICU admission, body mass index and age were found to have a high relative importance (> 0.7). CONCLUSIONS: In patients with COVID-19 in the ICU, both severely impaired LV function and impaired RV function may have adverse prognostic implications, but older age and inflammatory markers appear to have a greater impact. A combination of echocardiographic and laboratory investigations as well as demographic and clinical characteristics appears appropriate for risk stratification in patients with COVID-19 who are admitted to the ICU.

Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society.

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.

First-Phase Ejection Fraction, a Measure of Preclinical Heart Failure, Is Strongly Associated With Increased Mortality in Patients With COVID-19.

Presence of heart failure is associated with a poor prognosis in patients with coronavirus disease 2019 (COVID-19). The aim of the present study was to examine whether first-phase ejection fraction (EF1), the ejection fraction measured in early systole up to the time of peak aortic velocity, a sensitive measure of preclinical heart failure, is associated with survival in patients hospitalized with COVID-19. A retrospective outcome study was performed in patients hospitalized with COVID-19 who underwent echocardiography (n=380) at the West Branch of the Union Hospital, Wuhan, China and in patients admitted to King's Health Partners in South London, United Kingdom. Association of EF1 with survival was performed using Cox proportional hazards regression. EF1 was compared in patients with COVID-19 and in historical controls with similar comorbidities (n=266) who had undergone echocardiography before the COVID-19 pandemic. In patients with COVID-19, EF1 was a strong predictor of survival in each patient group (Wuhan and London). In the combined group, EF1 was a stronger predictor of survival than other clinical, laboratory, and echocardiographic characteristics including age, comorbidities, and biochemical markers. A cutoff value of 25% for EF1 gave a hazard ratio of 5.23 ([95% CI, 2.85-9.60]; P<0.001) unadjusted and 4.83 ([95% CI, 2.35-9.95], P<0.001) when adjusted for demographics, comorbidities, hs-cTnI (high-sensitive cardiac troponin), and CRP (C-reactive protein). EF1 was similar in patients with and without COVID-19 (23.2±7.3 versus 22.0±7.6%, P=0.092, adjusted for prevalence of risk factors and comorbidities). Impaired EF1 is strongly associated with mortality in COVID-19 and probably reflects preexisting, preclinical heart failure.

Impact and Determinants of High-Sensitivity Cardiac Troponin-T Concentration in Patients With COVID-19 Admitted to Critical Care.

Cardiac Troponin (hs-TnT) elevation has been reported in unselected patients hospitalized with COVID-19 however the mechanism and relationship with mortality remain unclear. Consecutive patients admitted to a high-volume intensive care unit (ICU) in London with severe COVID-19 pneumonitis were included if hs-TnT concentration at admission was known. Kaplan-Meier survival analysis performed, with cohorts classified a priori by multiples of the upper limit of normal (ULN). 277 patients were admitted during a 7-week period in 2020; 176 were included (90% received invasive ventilation). hs-TnT at admission was 16.5 (9.0 to 49.3) ng/L, 56% had concentrations >ULN. 56 patients (31.8%) died during the index admission. Admission hs-TnT level was lower in survivors (12.0 (8.0-27.8) vs 28.5 (14.0 to 81.0) ng/L, p = 0.001). Univariate predictors of mortality were age, APACHE-II Score and admission hs-TnT (HR 1.73, p = 0.007). By multivariate regression, only age (HR 1.33, CI: 1.16.to 1.51, p < 0.01) and admission hs-TnT (HR 1.94, CI: 1.22 to 3.10, p = 0.006) remained predictive. Survival was significantly lower when admission hs-TnT was >ULN (log-rank p-value<0.001). Peak hs-TnT was higher in those who died but was not predictive of death after adjustment for other factors. In conclusion, in critically ill patients with COVID-19 pneumonitis, the hs-TnT level at admission is a powerful independent predictor of the likelihood of surviving to discharge from ICU. In most cases, hs-TnT elevation does not represent major myocardial injury but acts as a sensitive integrated biomarker of global stress. Whether stratification based on admission Troponin level could be used to guide prognostication and management warrants further evaluation.

The paravertebral panto: it's behind you!

This case report highlights the utility of paravertebral (PV) imaging in the diagnosis of aortic dissection, the evaluation of left ventricular systolic function and drawing the distinction between pleural and pericardial effusions. In this case, less attenuation of the ultrasound beam, reduced lung viscosity due to pleural effusions and less impedance mismatch between media led to images of superior quality and high diagnostic value. This supports the use of paravertebral imaging as an adjunct to conventional echocardiography windows, particularly when conventional transthoracic imaging proves challenging. LEARNING POINTS: PV images provide superior resolution when interrogating the descending aorta and thus can reveal incidental findings such as aortic dissection.PV imaging provides clearer delineation between pericardial and pleural effusions.Additional information may be obtained from the PV window in relation to left ventricular systolic function particularly in the setting of suboptimal transthoracic image quality.

Intracardiac Right-to-Left Shunt Impeding Liberation From Veno-Venous Extracorporeal Membrane Oxygenation: Two Case Studies.

OBJECTIVES: Veno-venous extracorporeal membrane oxygenation is an increasingly used form of advanced respiratory support, but its effects on the physiology of the right heart are incompletely understood. We seek to illustrate the impact of veno-venous extracorporeal membrane oxygenation return blood flow upon the right atrium by considering the physiologic effects during interatrial shunting. PATIENTS: Two veno-venous extracorporeal membrane oxygenation patients in whom an extracorporeal membrane oxygenation induced right-to-left interatrial shunt appears to have created a barrier to liberation from extracorporeal support. CONCLUSIONS: Veno-venous extracorporeal membrane oxygenation return flow generates a high-pressure jet that has potential to exert focal pressure upon the intra-atrial septum. In patients with potential for interatrial flow, this may lead to a right-to-left shunt, which becomes physiologically apparent only when sweep gas flow is ceased.

CRITICAL CARE ECHO ROUNDS: Extracorporeal membrane oxygenation.

UNLABELLED: Extracorporeal membrane oxygenation (ECMO) is an advanced form of organ support indicated in selected cases of severe cardiovascular and respiratory failure. Echocardiography is an invaluable diagnostic and monitoring tool in all aspects of ECMO support. The unique nature of ECMO, and its distinct effects upon cardio-respiratory physiology, requires the echocardiographer to have a sound understanding of the technology and its interaction with the patient. In this article, we introduce the key concepts underpinning commonly used modes of ECMO and discuss the role of echocardiography. CASE: A 38-year-old lady, with no significant past medical history, was admitted to her local hospital with group A Streptococcal pneumonia. Rapidly progressive respiratory failure ensued and, despite intubation and maximal ventilatory support, adequate oxygenation proved impossible. She was attended by the regional severe respiratory failure service who established her on veno-venous (VV)-ECMO for respiratory support. Systemic oxygenation improved; however, significant cardiovascular compromise was encountered and echocardiography demonstrated a severe septic cardiomyopathy (ejection fraction <15%, aortic velocity time integral 5.9 cm and mitral regurgitation dP/dt 672 mmHg/s). Her ECMO support was consequently converted to a veno-veno-arterial configuration, thus providing additional haemodynamic support. As the sepsis resolved, arterial ECMO support was weaned under echocardiographic guidance; subsequent resolution of intrinsic respiratory function allowed the weaning of VV-ECMO support. The patient was liberated from ECMO 7 days after hospital admission.

Multimodality Imaging of Heart Valve Disease / Técnicas de Imagem Multimodal para Valvopatia Multimodality

Unidentified heart valve disease is associated with a significant morbidity and mortality. It has therefore become important to accurately identify, assess and monitor patients with this condition in order that appropriate and timely intervention can occur. Although echocardiography has emerged as the predominant imaging modality for this purpose, recent advances in cardiac magnetic resonance and cardiac computed tomography indicate that they may have an important contribution to make. The current review describes the assessment of regurgitant and stenotic heart valves by multimodality imaging (echocardiography, cardiac computed tomography and cardiac magnetic resonance) and discusses their relative strengths and weaknesses.

Doenças valvares cardíacas não identificadas são associadas com significativas taxas de morbidade e mortalidade. Dessa forma, é importante que os pacientes com essa condição sejam corretamente identificados, investigados e monitorizados para que a apropriada intervenção seja feita a tempo. Contudo, a modalidade ecocardiográfica surgiu predominantemente com esta finalidade, recentes avanços em ressonância magnética cárdica e tomografia computadorizada cardíaca indicam que provavelmente ambos tenham importante contribuição. A atual revisão descreve a avaliação das válvulas cardíacas regurgitantes e estenosadas através de multimodalidade (diversos tipos) de imagens (ecocardiografia, tomografia computorizada cardíaca e ressonância magnética cardíaca), promovendo a discussão de seus pontos positivos e negativos.

Multimodality imaging of heart valve disease.

Unidentified heart valve disease is associated with a significant morbidity and mortality. It has therefore become important to accurately identify, assess and monitor patients with this condition in order that appropriate and timely intervention can occur. Although echocardiography has emerged as the predominant imaging modality for this purpose, recent advances in cardiac magnetic resonance and cardiac computed tomography indicate that they may have an important contribution to make. The current review describes the assessment of regurgitant and stenotic heart valves by multimodality imaging (echocardiography, cardiac computed tomography and cardiac magnetic resonance) and discusses their relative strengths and weaknesses.

A training programme in screening echocardiography.

BACKGROUND: Although the value of echocardiography in acutely unwell patients is well established, it is often difficult to deliver conventional studies immediately. This has led to the development of training programmes in screening echocardiography. CONTEXT: Echocardiography is a difficult skill to master and requires an integration of knowledge-based learning and mentored practical training. INNOVATION: We developed a three-stage programme: (1) a 1-day course containing didactic lectures on normal and abnormal pathology, a 2-hour practical element with rotation through different tutors then seminars and self-assessment, with an interactive quiz; (2) a period of consolidation via apprenticeship with a recognised trainer; and (3) formal assessment. IMPLICATIONS: We propose a specific training programme to teach the difficult practical skill of screening echocardiography. The use of theoretical and practical elements with structured teaching and an apprenticeship may serve as a model for teaching other practical skills in clinical medicine.