The Clinical Utility of Noninvasive Forrester Classification in Acute Heart Failure from PREDICT Study.

The Forrester classification plays a crucial role in comprehending the underlying pathophysiology of heart failure (HF) and is employed to categorize the severity and predict the outcomes of patients with acute HF. Our objective was to assess the predictive value of the Forrester classification, based on noninvasive hemodynamic measurements obtained through Doppler echocardiography at admission, in forecasting the short-term prognosis posthospitalization of patients with acute HF. Patients were recruited for the Prospect trial to elucidate the utility of EchocarDIography-based Cardiac ouTput in acute heart failure (PREDICT) study, a multicenter, prospective study conducted in Japan. Participants were stratified into 4 profiles using cardiac index (CI) and early mitral filling velocity (E)/early-diastolic mitral annular velocity (e') ratio obtained from Doppler echocardiography upon admission (profile I: CI >2.2, E/e' ≤15, profile II: CI >2.2, E/e' >15, profile III: CI ≤2.2, E/e' ≤15, profile IV: CI ≤2.2, E/e' >15). The primary composite outcome of the study was all-cause mortality or worsening HF during the 14 days of hospitalization. Cox proportional hazards model analysis was employed to identify prognostic factors during the observation period. A total of 270 subjects, with a mean age of 74 ± 14 years and a male proportion of 60%, were enrolled in the study. During the 14-day period of hospitalization, 58 participants (22%) had a composite outcome. Patients with low CI (i.e., profiles III and IV) demonstrated an elevated risk of composite outcome after adjusting for confounding variables, as evidenced by the adjusted hazard ratios of 5.85 (95% confidence interval 1.17 to 29.09, p <0.01, vs profile III) and 6.50 (95% confidence interval 1.53 to 27.68, p <0.01, vs profile IV) in comparison with profile I, respectively. In conclusion, the Forrester classification, derived from noninvasive Doppler echocardiography at admission, may predict early deterioration in patients hospitalized with acute HF.

Results of PRospect trial to Elucidate the utility of EchocarDiography-based Cardiac ouTput in acute heart failure (PREDICT).

BACKGROUND: The predictive value of echocardiographic parameters for early worsening heart failure (WHF), worsening of symptoms of heart failure requiring intensification of therapy during an admission for acute decompensated heart failure (ADHF), has not been elucidated. METHODS: Sixteen centers in Japan prospectively enrolled 303 ADHF hospitalized patients who did not receive positive inotropic agents as an initial therapy. Physical and Doppler echocardiographic examinations were performed before the initial therapy and the association of low output findings and occurrence of early WHF were tested. RESULTS: Early WHF occurred in 63 patients with a median duration of 6 (IQR: 2-23) hours from the administration of the initial therapy. In patients with left ventricular (LV) ejection fraction <40% (N = 153), echocardiographic stroke volume index, and cardiac index showed greater c-index [95% confidence interval, 0.71 (0.61-0.79) and 0.72 (0.63-0.80), respectively] compared to single low perfusion finding (symptomatic hypotension, reduced pulse pressure, and impaired mentation) other than cool extremities. When physical findings were combined (low perfusion score), the predictive ability improved to the similar levels of echocardiographic LV output parameters [c-index: 0.69 (0.60-0.76)]. However, addition of cardiac index significantly improved the prognostic ability when added to low perfusion score [0.82 (0.74-0.87), p < 0.001]. In contrast, in patients with LV ejection fraction ≥40% (N = 150), low perfusion score, rather than LV output parameters, was predictive of early WHF [c-index: 0.73 (0.56-0.85)]. CONCLUSIONS: We demonstrated the predictive value of echocardiographic LV output indices for early WHF in ADHF patients with LV systolic dysfunction. These data support the motivation for routine use of echocardiography for initial assessment of ADHF.

Clinical outcomes of transcatheter aortic valve implantation (TAVI) in nonagenarians from the optimized catheter valvular intervention-TAVI registry.

OBJECTIVES: The purpose of this study was to investigate 30-day and 2-year clinical outcomes, and predictors of 2-year mortality in nonagenarians undergoing transcatheter aortic valve implantation (TAVI). BACKGROUND: TAVI has been applied to nonagenarians. However, sufficient clinical data in nonagenarians who could benefit from TAVI are limited. METHODS: We evaluated the data from the optimized catheter valvular intervention-TAVI registry. Clinical outcomes were compared between patients' age ≥90 years and age <90 years. Predictive factors of 2-year mortality were assessed by multivariable Cox regression analyses. RESULTS: From October 2013 to May 2017, a total of 375 nonagenarians (age ≥90 years) and 2,213 younger patients (age <90 years) were included. Although nonagenarians had a higher surgical risk score, 30-day clinical outcomes were similar between two groups. There were no significant differences in 2-year mortality (22.0% vs. 17.3%; p = .11) and stroke (5.5% vs. 3.9%; p = .31); however, 2-year heart failure readmission was higher in nonagenarians (13.3% vs. 9.0%; p = .03). After adjusting covariates, age ≥90 years was not independent predictor for 2-year outcomes. In nonagenarians, female sex (hazard ratio [HR] = 0.43; 95% confidence interval [CI] = 0.26-0.74; p = .002), chronic kidney disease grade ≥4 (HR = 2.14; 95% CI = 1.21-3.64; p = .01), and Clinical Frailty Scale ≥4 (HR = 1.82; 95% CI = 1.02-3.42; p = .04) were independently associated with 2-year mortality. CONCLUSIONS: Clinical outcomes of TAVI in selected nonagenarians were favorable. Severe renal dysfunction and frailty may be important factors to predict mid-term mortality after TAVI in nonagenarians.

Midterm outcomes after the rescue THV-in-THV procedure: Insights from the multicenter prospective OCEAN-TAVI registry.

OBJECTIVES: To confirm whether the rescue transcatheter heart valve in the transcatheter heart valve (THV-in-THV) procedure is effective and feasible, we aimed to assess the midterm outcomes following rescue THV-in-THV procedures. The trends in the usage of the rescue THV-in-THV procedure at the time of transcatheter aortic valve implantation (TAVI) have also been explored. BACKGROUND: Midterm outcomes of the rescue THV-in-THV procedure have been poorly defined, though it is popular as an effective method to bail-out some complications in TAVI. METHODS: We reviewed data from the Optimized transCathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry and compared the outcomes of TAVI with rescue THV-in-THV and TAVI without rescue THV-in-THV. We also examined the annual rates of rescue THV-in-THV procedures in all the TAVI procedures between 2013 and 2017. RESULTS: Among 2,588 patients who underwent TAVI, 26 patients have required rescue THV-in-THV for valve malposition (n = 23) or severe transvalvular regurgitation because of stuck THV leaflets (n = 3). Three cases needed an open conversion, and two died in the hospital. The rates of new permanent pacemaker implantation, acute kidney injury, and stroke were higher in the THV-in-THV group. A two-year cumulative survival and echocardiographic outcomes succeeding rescue THV-in-THV procedure were comparable to non-THV-in-THV cases. The rate of rescue THV-in-THV procedure lessened from 2.6% in 2013 to 0.6% in 2017. CONCLUSIONS: The rescue THV-in-THV procedure is an effective and feasible option for THV malpositioning and stuck valve. It has given a comparable survival and a stable valve function over midterm observation periods.

Study protocol for prospect trial to elucidate the utility of echocardiography-based cardiac output in acute heart failure (PREDICT).

BACKGROUND: Early worsening heart failure (WHF), defined as worsening of symptoms and signs of heart failure requiring intensification of medical or mechanical therapy during an admission for acute decompensated heart failure (ADHF), has recently been recognized as a risk of morbidity or mortality after the discharge. Although echocardiographic parameters of left ventricular (LV) output has been shown to be associated with long-term outcome in heart failure patients, its predictive value for early WHF has not been elucidated. METHODS: Prospect trial to Elucidate the utility of EchocarDiography-based Cardiac output in acute heart failure (PREDICT) is a multicenter, nonrandomized, prospective observational study to test the predictive value of echocardiographic LV output parameters for early WHF in ADHF patients. We will enroll patients admitted to 16 participating hospitals due to ADHF who did not receive positive inotropic agents as an initial therapy. Primary outcome will be set at early WHF defined as need for initiation of positive inotropic agents within 7 days after the admission. Predictive accuracy will be compared between Doppler echocardiographic LV output (stroke distance, stroke volume index, and cardiac index) and low perfusion findings assessed by physical examination. RESULTS: N/A. CONCLUSIONS: The PREDICT is expected to provide large data set to test the predictive value of echocardiographic LV output for early WHF in ADHF patients.

Hemodynamics and Prognostic Impact of Concomitant Mitral Stenosis in Patients Undergoing Surgical or Transcatheter Aortic Valve Replacement for Aortic Stenosis.

BACKGROUND: Mitral stenosis frequently coexists in patients with severe aortic stenosis. Mitral stenosis severity evaluation is challenging in the setting of combined aortic stenosis and mitral stenosis because of hemodynamic interactions between the 2 valve lesions. The impact of aortic valve replacement (AVR) for severe aortic stenosis on mitral stenosis is unknown. This study aimed to assess the effect of AVR on mitral stenosis hemodynamics and the clinical outcomes of patients with severe aortic stenosis with and without mitral stenosis. METHODS: We retrospectively investigated patients who underwent surgical AVR or transcatheter AVR for severe aortic stenosis from 2008 to 2015. Mean transmitral gradient by Doppler echocardiography ≥4 mm Hg was identified as mitral stenosis; patients were then stratified according to mitral valve area (MVA, by continuity equation) as >2.0 cm2 or ≤2.0 cm2. MVA before and after AVR in patients with mitral stenosis were evaluated. Clinical outcomes of patients with and without mitral stenosis were compared using 1:2 matching for age, sex, left ventricular ejection fraction, method of AVR (surgical AVR versus transcatheter AVR) and year of AVR. RESULTS: Of 190 patients with severe aortic stenosis and mitral stenosis (age 76±9 years, 42% men), 184 were matched with 362 with severe aortic stenosis without mitral stenosis. Among all mitral stenosis patients, the mean MVA increased after AVR by 0.26±0.59 cm2 (from 2.00±0.50 to 2.26±0.62 cm2, P<0.01). MVA increased in 105 (55%) and remained unchanged in 34 (18%). Indexed stroke volume ≤45 mL/m2 (odds ratio [OR] 2.40; 95% CI, 1.15-5.01; P=0.020) and transcatheter AVR (OR, 2.36; 95% CI, 1.17-4.77; P=0.017) were independently associated with increase in MVA. Of 107 with significant mitral stenosis (MVA ≤2.0 cm2), MVA increased to >2.0 cm2 after AVR in 52 (49%, pseudo mitral stenosis) and remained ≤2.0 cm2 in 55 (51%, true mitral stenosis). During follow-up of median 2.9 (0.7-4.9) years, true mitral stenosis was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.88; 95% CI, 1.20-2.94; P<0.01). CONCLUSIONS: MVA improved after AVR in nearly half of patients with severe aortic stenosis and mitral stenosis. MVA remained ≤2.0 cm2 (true mitral stenosis) in nearly half of patients with severe aortic stenosis and significant mitral stenosis; this was associated with worse survival among patients undergoing AVR for severe aortic stenosis.

Impact of transcatheter aortic valve replacement on hemodynamic status in patients with aortic stenosis and mitral stenosis: Doppler echocardiographic study.

BACKGROUND: Mitral stenosis (MS) is often concomitant with aortic stenosis (AS). However, little is known about the functional status following transcatheter aortic valve replacement (TAVR) alone in patients with severe AS and MS and the impact of TAVR for AS on MS hemodynamics. METHODS: We enrolled 11 patients (age 83.6±4.7 years, eight women) with severe AS and MS who underwent TAVR. We compared New York Heart Association (NYHA) functional class and mean transmitral pressure gradient (MPG), mitral valve area (MVA), and stroke volume (SV) measured by transthoracic Doppler echocardiography between baseline and after TAVR. We also examined the calcification of the mitral annulus and mitral leaflet opening. RESULTS: NYHA functional class improved after TAVR in all 11 patients. As SV increased after TAVR (52±12mL to 63±18mL, p=0.041), MPG decreased and MVA increased (6.9±3.8mmHg to 5.1±2.5mmHg, p=0.011 for MPG and 1.12±0.25cm2 to 1.49±0.43cm2, p=0.035 for MVA). However, MPG increased in one patient in whom calcification extended into the entire anterior mitral leaflet (AML) and AML mobility was severely reduced. CONCLUSIONS: NYHA functional class and hemodynamic status of MS improved after TAVR in patients with severe AS and MS. TAVR might provide therapeutic efficacy for selected symptomatic severe AS patients with MS.

Prognostic significance of residual functional mitral regurgitation in hospitalized heart failure patients with chronic atrial fibrillation and preserved ejection fraction after medical therapies.

BACKGROUND: Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation (AF), even without left-ventricular (LV) systolic dysfunction, as a result of left atrial enlargement. The purpose of this study was to evaluate the prognostic significance of residual functional MR in hospitalized heart failure patients with chronic AF and preserved LV ejection fraction (pEF) after medical therapies. METHODS: In this retrospective multi-center study, the determinants of post-discharge prognosis (cardiac death and re-hospitalization for worsening heart failure) were examined in 54 hospitalized heart failure patients with chronic AF and pEF at discharge. RESULTS: Of the 54 patients, 53 (98%) had mild or higher degrees of functional MR at hospitalization.At discharge, 47 (87%) still had functional MR, even after medical therapies [mild in 27 (50%), moderate in 16 (30%), and severe in 4 (7%)]. During the follow-up period (20 ± 16 months) after discharge, 16 (30%) patients met the composite end points. The grading of residual functional MR at discharge was the significant predictor of the end point (hazard ratio per one grade increase: 2.4, 95% confidence interval 1.1-5.5, p = 0.035). The greater the residual functional MR was, the lower the event-free rate from the end point was in the Kaplan-Meier curve analysis (p = 0.0069 for trend). CONCLUSIONS: A substantial proportion of patients hospitalized due to heart failure with chronic AF have residual functional MR at discharge, even with pEF after medical therapies, and the MR is related to future heart failure events.

Effect of a do-not-resuscitate order on the quality of care in acute heart failure patients: a single-center cohort study.

BACKGROUND: A do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes. AIM: To analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months. DESIGN: Retrospective cohort study. METHODS: The medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders. RESULTS: In 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant). CONCLUSION: DNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients.

Superiority of novel automated assessment of aortic annulus by intraoperative three-dimensional transesophageal echocardiography in patients with severe aortic stenosis: Comparison with conventional cross-sectional assessment.

BACKGROUND: Previous studies have demonstrated that three-dimensional (3D) transesophageal echocardiography (TEE) is an alternative to multi-detector computed tomography (MDCT) for aortic valve sizing in transcatheter aortic valve replacement (TAVR). However, conventional cross-sectional analysis of aortic annulus by 3D TEE has some limitations such as lengthy analytical time. A novel software for automated valve measurement has been developed for 3D TEE. We evaluated the accuracy and analytical time of aortic annular measurements using this novel automated software in the clinical setting. METHODS: We retrospectively studied 43 patients with symptomatic severe aortic stenosis (AS) who underwent TAVR. All patients underwent intraoperative TEE and MDCT. We measured aortic annular area by automated, semi-automated, and cross-sectional methods using 3D TEE datasets. These measurements were compared to the corresponding MDCT reference values. We also compared the analytical time of the three methods. RESULTS: Automated and semi-automated analyses required significantly shorter analytical time compared to cross-sectional analysis (automated: 30.1±5.79s, semi-automated: 74.1±15.0s, manual: 81.8±18.5s, p<0.05). Compared to MDCT measurement (393.7±81.0mm2), annular areas measured by automated and cross-sectional methods were significantly smaller (automated: 380.6±77.1mm2, cross-sectional: 374.7±76.8mm2, p<0.05), while that obtained by semi-automated method was not significantly different (387.7±75.8mm2). Annular areas determined by semi-automated and cross-sectional analyses had narrower limits of agreement (LOA) with MDCT measurements, compared to automated analysis (automated: -68.6 to 94.7mm2, semi-automated: -48.3 to 60.2mm2, cross-sectional: -40.0 to 77.9mm2). Measurements by all three methods using 3D TEE showed high correlation with MDCT measurement (automated: r=0.86, semi-automated: r=0.94, cross-sectional: r=0.93). CONCLUSIONS: For aortic annular measurements using 3D TEE in AS patients, semi-automated analysis using the novel automated software reduced analytical time while maintaining similar accuracy compared to the conventional cross-sectional analysis. This automated software may have acceptable feasibility in the clinical setting.

Recurrent aortic root pseudoaneurysm after transcatheter occlusion-A word of caution.

A 48-year-old male developed a recurrent aortic-root pseudoaneurysm after surgical repair for acute dissection. Although the initial closure of the pseudoaneurysm was successfully managed by transcatheter endovascular occlusion and coiling utilizing a hybrid transapical and transfemoral approach, the pseudoaneurysm was recanalized after 3 months and a third-time surgical repair was required. The potential risk for recurrence of pseudoaneurysms should be considered when applying endovascular occlusion devices to treat aortic root anatomy.

Reduced variability of visual left ventricular ejection fraction assessment with reference images: The Japanese Association of Young Echocardiography Fellows multicenter study.

BACKGROUND: Visual estimation of left ventricular ejection fraction (LVEF) is widely applied to confirm quantitative EF. However, visual assessment is subjective, and variability may be influenced by observer experience. We hypothesized that a learning session might reduce the misclassification rate. METHODS: Protocol 1: Visual LVEFs for 30 cases were measured by 79 readers from 13 cardiovascular tertiary care centers. Readers were divided into 3 groups by their experience: limited (1-5 years, n=28), intermediate (6-11 years, n=26), and highly experienced (12-years, n=25). Protocol 2: All readers were randomized to assess the effect of a learning session with reference images only or feedback plus reference images. After the session, 20 new cases were shown to all readers following the same methodology. To assess the concordance and accuracy pre- and post-intervention, each visual LVEF measurement was compared to overall average values as a reference. RESULTS: Experience affected the concordance in visual EF values among the readers. Groups with intermediate and high experience showed significantly better mean difference (MD), standard deviation (SD), and coefficient of variation (CV) than those with limited experience at baseline. The learning session with reference image reduced the MD, SD, and CV in readers with limited experience. The learning session with reference images plus feedback also reduced proportional bias. Importantly, the misclassification rate for mid-range EF cases was reduced regardless of experience. CONCLUSION: This large multicenter study suggested that a simple learning session with reference images can successfully reduce the misclassification rate for LVEF assessment.

Significance of intravascular ultrasound and exercise stress echocardiography in diagnosis of exercise-induced vasospastic angina at the site of moderate stenosis.

Recently, exercise-induced spastic coronary artery occlusion at the site of moderate stenosis, which Prinzmetal's angina or cardiac syndrome X does not cover, was reported. Multi-modality imaging is important for the diagnosis of coronary artery disease with a complex ischemic mechanism. However, the previous report did not include findings from intracoronary imaging at the site of moderate coronary stenosis. We report a case of exercise-induced vasospastic angina at the site of moderate stenosis, where multi-modality imaging, including exercise stress echocardiography and intravascular ultrasound, was utilized to make a definitive diagnosis and investigate underlying causes.

Association of postprocedural aortic regurgitation with mitral regurgitation worsened after transcatheter aortic valve replacement.

BACKGROUND: There is a paucity of investigation which demonstrates a predictor of mitral regurgitation (MR) worsened after aortic valve replacement (TAVR). AIM: The aim of this study was to identify the predictor of worsened MR after transcatheter TAVR. METHODS: We retrospectively studied a total of 209 patients with mild or less MR at baseline who underwent TAVR for the treatment of severe aortic stenosis with the balloon-expandable device. We found the presence of MR worsened after TAVR in 6% (12 patients) of all patients. Moderate or more postprocedural aortic regurgitation (AR) (odds ratio, 8.104; 95% confidence interval, 1.78-36.87; P = .007) was identified as a predictor of MR worsening after TAVR. In-hospital outcomes indicated that patients within whom MR worsened suffered congestive heart failure more than those with unchanged or improved MR after TAVR (P < .05). CONCLUSION: Significant postprocedural AR was associated with MR worsened from mild or less to moderate or more after TAVR. Worsened MR might affect in-hospital congestive heart failure.

Accuracy and usefulness of aortic annular measurement using real-time three-dimensional transesophageal echocardiography: Comparison with direct surgical sizing.

BACKGROUND: There is a paucity of data that demonstrates a clinical impact of anatomical measurements of the aortic annulus by three-dimensional (3D) transesophageal echocardiography (TEE) on surgical aortic valve replacement (AVR). The aim of this study is to validate the accuracy of 3D TEE measurements compared with the direct intraoperative annular diameter and to investigate an impact of 3D TEE on a prediction of AVR with aortic annular enlargement (AAE). METHODS AND RESULTS: We retrospectively enrolled 61 patients who underwent both two-dimension (2D) and 3D TEE and transthoracic echocardiography (TTE) before AVR. The annular diameters were measured noninvasively with 2D TEE (D2D) and TTE (DTTE) in a classical manner and the area- and perimeter-derived annular diameters (Darea, Dperim) were measured from using 3D TEE analysis. Intraoperative annular diameter was measured with the manufacture's sizer (Dintraope). Darea showed the best agreement with Dintraope in the Bland-Altman analysis. Darea, Dperim, D2D, and DTTE correlated well with Dintraope (r=0.821, 0.820, 0.532, and 0.610, respectively; all p<0.001). Three patients underwent AVR with AAE and the specificity of Dperim for prediction of AAE was significantly higher than D2D (p=0.008). CONCLUSIONS: 3D TEE measurement of aortic annular diameter showed better agreement with the direct intraoperative measurement than 2D TEE and TTE measurements. 3D TEE measurement could predict AVR with AAE more accurately than 2D TEE and TTE measurements.

Delayed right ventricular defibrillation lead perforation presenting as cardiac tamponade and treated surgically.

Right ventricular perforation leading to cardiac tamponade can occur during the chronic phase after cardiac device implantation. Physicians who manage the pacemaker clinic must be alert to the wide range of symptoms and signs that can accompany delayed right ventricular perforation. Surgical rather than percutaneous lead extraction may be prudent.

Successfully Treated Nonocclusive Mesenteric Ischemia After Transcatheter Aortic Valve Replacement.

An 80-year-old man with symptomatic severe aortic stenosis underwent transcatheter aortic valve replacement. Postoperatively, the patient was hemodynamically stable without inotropic or mechanical support. Approximately 30 hours after the procedure, he developed severe abdominal pain, and a blood test result showed elevated serum lactate level. We suspected nonocclusive mesenteric ischemia and performed emergency selective angiography of the superior mesenteric artery, which showed vasospasm. We confirmed the diagnosis of nonocclusive mesenteric ischemia, and it was treated successfully with intraarterial infusion of vasodilators into the superior mesenteric artery.

Clinical use of echocardiography in structural heart disease.

Recently, a development of devices for transcatheter interventions, such as transcatheter aortic valve implantation for aortic stenosis, percutaneous mitral valve repair for mitral regurgitation, and percutaneous closure of atrial septal defect, has led to a greatly expanded armamentarium of catheter-based approaches for patients with structural heart disease (SHD). Comorbidity and anatomical limitations specific to each procedure are known to influence outcomes during and after the intervention. Therefore, risk stratification of the intervention including anatomical and functional assessments is critically important. Furthermore, echocardiography reveals both physiological and anatomical abnormalities of SHD in real-time even in the operation theater. Consequently, echocardiography plays an essential role in providing not only preoperative assessment of SHD but also intra-procedural monitoring and postoperative follow-up. This document is intended as a reference for cardiac surgeons using echocardiography clinically for patients with SHD, particularly those with valvular heart disease and atrial septal defect.