The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography.

Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/'preserved' left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258-271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient's bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59-G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.

Left and right ventricular strain-volume/area loops: a narrative review of current physiological understanding and potential clinical value.

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.

Role and application of three-dimensional transthoracic echocardiography in the assessment of left and right ventricular volumes and ejection fraction: a UK nationwide survey.

Three-dimensional echocardiography (3DE) imaging has permitted advancements in the quantification of left ventricular (LV) and right ventricular (RV) volumes and ejection fraction. We evaluated the availability of 3DE equipment / analysis software, the integration of 3DE assessment of the LV and RV in routine clinical practice, current training provisions in 3DE, and aimed to ascertain barriers preventing the routine use of 3DE for volumetric analysis. Through the British Society of Echocardiography (BSE) regional representatives' network, echocardiographers were invited to participate in an open online survey. A total of 181 participants from echocardiography departments in the United Kingdom (UK), the majority from tertiary centres (61%), completed the 28-question survey. For 3DE quantification, 3DE-LV was adopted more frequently than 3DE-RV (48% vs 11%, respectively). Imaging feasibility was a recognised factor in 3DE RV and LV adoption. Many respondents had access to 3D probes (93%). The largest observed barriers to 3DE routine use were training deficiencies, with 83% reporting they would benefit from additional training opportunities and the duration of time permitted for the scan, with 68% of responders reporting allowances of less than the BSE standard of 45-60 min per patient (8% < 30-min). Furthermore, of those respondents who had undertaken professional accreditation, competence in 3DE was not formally assessed in 89%. This UK survey also reported good accessibility to magnetic resonance imaging (72%), which was related to overall 3DE adoption. In summary, although 3DE is now readily available, it remains underutilised. Further training opportunities, integrated formal assessment, improved adoption of BSE minimum recommended scanning times, alongside industry and societal support, may increase 3DE utilisation in routine practice.

Impact of ECG data format on the performance of machine learning models for the prediction of myocardial infarction.

Background We aim to determine which electrocardiogram (ECG) data format is optimal for ML modelling, in the context of myocardial infarction prediction. We will also address the auxiliary objective of evaluating the viability of using digitised ECG signals for ML modelling. Methods Two ECG arrangements displaying 10s and 2.5 s of data for each lead were used. For each arrangement, conservative and speculative data cohorts were generated from the PTB-XL dataset. All ECGs were represented in three different data formats: Signal ECGs, Image ECGs, and Extracted Signal ECGs, with 8358 and 11,621 ECGs in the conservative and speculative cohorts, respectively. ML models were trained using the three data formats in both data cohorts. Results For ECGs that contained 10s of data, Signal and Extracted Signal ECGs were optimal and statistically similar, with AUCs [95% CI] of 0.971 [0.961, 0.981] and 0.974 [0.965, 0.984], respectively, for the conservative cohort; and 0.931 [0.918, 0.945] and 0.919 [0.903, 0.934], respectively, for the speculative cohort. For ECGs that contained 2.5 s of data, the Image ECG format was optimal, with AUCs of 0.960 [0.948, 0.973] and 0.903 [0.886, 0.920], for the conservative and speculative cohorts, respectively. Conclusion When available, the Signal ECG data should be preferred for ML modelling. If not, the optimal format depends on the data arrangement within the ECG: If the Image ECG contains 10s of data for each lead, the Extracted Signal ECG is optimal, however, if it only uses 2.5 s, then using the Image ECG data is optimal for ML performance.

The effect of long-term soccer training on left ventricular structure and function in elite male youth soccer players.

AIMS: Cardiac adaptations in elite, male adolescent youth soccer players have been demonstrated in relation to training status. The time course of these adaptations and the delineation of the influence of volatile growth phases from the training effect on these adaptations remain unclear. Consequently, the aims of the study were to evaluate the impact of 3 years of elite-level soccer training on changes in left ventricular (LV) structure and function in a group of highly trained elite youth male soccer players (SP) as they transitioned through the pre-to-adolescent phase of their growth. METHODS: Twenty-two male youth SP from the highest Level of English Premier League Academy U-12 teams were evaluated once a year for three soccer seasons as the players progressed from the U-12 to U-14 teams. Fifteen recreationally active control participants (CON) were also evaluated over the same 3-year period. Two-dimensional transthoracic echocardiography was used to quantify LV structure and function. RESULTS: After adjusting for the influence of growth and maturation, training-induced increases in Years 2 and 3 were noted for: LV end diastolic volume (LVEDV; p = 0.02) and LV end systolic volume (LVESV; p = 0.02) in the SP compared to CON. Training-induced decrements were noted for LV ejection fraction (LVEF; p = 0.006) and TDI-S' (p < 0.001). CONCLUSIONS: An increase in training volume (Years 2 and 3) were aligned with LV volumetric adaptations and decrements in systolic function in the SP that were independent from the influence of rapid somatic growth. Decrements in systolic function were suggestive of a functional reserve for exercise.

Coronary artery anomalies and the role of echocardiography in pre-participation screening of athletes: a practical guide.

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.

Allometric scaling for left ventricular mass and geometry in male and female athletes of mixed and endurance sports.

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.

Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF) using sensors embedded in the handles of supermarket trolleys: A feasibility study.

BACKGROUND: Atrial fibrillation (AF) increases the risk of death, stroke, heart failure, cognitive decline, and healthcare costs but is often asymptomatic and undiagnosed. There is currently no national screening program for AF. The advent of validated hand-held devices allows AF to be detected in non-healthcare settings, enabling screening to be undertaken within the community. METHOD AND RESULTS: In this novel observational study, we embedded a MyDiagnostick single lead ECG sensor into the handles of shopping trolleys in four supermarkets in the Northwest of England: 2155 participants were recruited. Of these, 231 participants either activated the sensor or had an irregular pulse, suggesting AF. Some participants agreed to use the sensor but refused to provide their contact details, or consent to pulse assessment. In addition, some data were missing, resulting in 203 participants being included in the final analyses. Fifty-nine participants (mean age 73.6 years, 43% female) were confirmed or suspected of having AF; 20 were known to have AF and 39 were previously undiagnosed. There was no evidence of AF in 115 participants and the remaining 46 recordings were non-diagnostic, mainly due to artefact. Men and older participants were significantly more likely to have newly diagnosed AF. Due to the number of non-diagnostic ECGs (n = 46), we completed three levels of analyses, excluding all non-diagnostic ECGs, assuming all non-diagnostic ECGs were masking AF, and assuming all non-diagnostic ECGs were not AF. Based on the results of the three analyses, the sensor's sensitivity (95% CI) ranged from 0.70 to 0.93; specificity from 0.15 to 0.97; positive predictive values (PPV) and negative predictive values (NPV) ranged from 0.24 to 0.56 and 0.55 to 1.00, respectively. These values should be interpreted with caution, as the ideal reference standard on 1934 participants was imperfect. CONCLUSION: The study demonstrates that the public will engage with AF screening undertaken as part of their daily routines using hand-held devices. Sensors can play a key role in identifying asymptomatic patients in this way, but the technology must be further developed to reduce the quantity of non-diagnostic ECGs.

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.

Unlocking the potential of artificial intelligence in sports cardiology: does it have a role in evaluating athlete's heart?

The integration of artificial intelligence (AI) technologies is evolving in different fields of cardiology and in particular in sports cardiology. Artificial intelligence offers significant opportunities to enhance risk assessment, diagnosis, treatment planning, and monitoring of athletes. This article explores the application of AI in various aspects of sports cardiology, including imaging techniques, genetic testing, and wearable devices. The use of machine learning and deep neural networks enables improved analysis and interpretation of complex datasets. However, ethical and legal dilemmas must be addressed, including informed consent, algorithmic fairness, data privacy, and intellectual property issues. The integration of AI technologies should complement the expertise of physicians, allowing for a balanced approach that optimizes patient care and outcomes. Ongoing research and collaborations are vital to harness the full potential of AI in sports cardiology and advance our management of cardiovascular health in athletes.

The impact of image and performance enhancing drugs on atrial structure and function in resistance trained individuals.

BACKGROUND: Image and performance enhancing drugs (IPEDs) are commonly used in resistance trained (RT) individuals and negatively impact left ventricular (LV) structure and function. Few studies have investigated the impact of IPEDs on atrial structure and function with no previous studies investigating bi-atrial strain. Additionally, the impact of current use vs. past use of IPEDs is unclear. METHODS: Utilising a cross-sectional design, male (n = 81) and female (n = 15) RT individuals were grouped based on IPED user status: current (n = 57), past (n = 19) and non-users (n = 20). Participants completed IPED questionnaires, anthropometrical measurements, electrocardiography, and transthoracic echocardiography with strain imaging. Structural cardiac data was allometrically scaled to body surface area (BSA) according to laws of geometric similarity. RESULTS: Body mass and BSA were greater in current users than past and non-users of IPEDs (p < 0.01). Absolute left atrial (LA) volume (60 ± 17 vs 46 ± 12, p = 0.001) and right atrial (RA) area (19 ± 4 vs 15 ± 3, p < 0.001) were greater in current users than non-users but this difference was lost following scaling (p > 0.05). Left atrial reservoir (p = 0.008, p < 0.001) and conduit (p < 0.001, p < 0.001) strain were lower in current users than past and non-users (conduit: current = 22 ± 6, past = 29 ± 9 and non-users = 31 ± 7 and reservoir: current = 33 ± 8, past = 39 ± 8, non-users = 42 ± 8). Right atrial reservoir (p = 0.015) and conduit (p = 0.007) strain were lower in current than non-users (conduit: current = 25 ± 8, non-users = 33 ± 10 and reservoir: current = 36 ± 10, non-users = 44 ± 13). Current users showed reduced LV diastolic function (A wave: p = 0.022, p = 0.049 and E/A ratio: p = 0.039, p < 0.001) and higher LA stiffness (p = 0.001, p < 0.001) than past and non-users (A wave: current = 0.54 ± 0.1, past = 0.46 ± 0.1, non-users = 0.47 ± 0.09 and E/A ratio: current = 1.5 ± 0.5, past = 1.8 ± 0.4, non-users = 1.9 ± 0.4, LA stiffness: current = 0.21 ± 0.7, past = 0.15 ± 0.04, non-users = 0.15 ± 0.07). CONCLUSION: Resistance trained individuals using IPEDs have bi-atrial enlargement that normalises with allometric scaling, suggesting that increased size is, in part, associated with increased body size. The lower LA and RA reservoir and conduit strain and greater absolute bi-atrial structural parameters in current than non-users of IPEDs suggests pathological adaptation with IPED use, although the similarity in these parameters between past and non-users suggests reversibility of pathological changes with withdrawal.

Exploratory assessment of right ventricular structure and function during prolonged endurance cycling exercise.

BACKGROUND: A reduction in right ventricular (RV) function during recovery from prolonged endurance exercise has been documented alongside RV dilatation. A relative elevation in pulmonary artery pressure and therefore RV afterload during exercise has been implicated in this post-exercise dysfunction but has not yet been demonstrated. The current study aimed to assess RV structure and function and pulmonary artery pressure before, during and after a 6-h cycling exercise bout. METHODS: Eight ultra-endurance athletes were recruited for this study. Participants were assessed prior to exercise supine and seated, during exercise at 2, 4 and 6 h whilst cycling seated at 75% maximum heart rate, and post-exercise in the supine position. Standard 2D, Doppler and speckle tracking echocardiography were used to determine indices of RV size, systolic and diastolic function. RESULTS: Heart rate and RV functional parameters increased from baseline during exercise, however RV structural parameters and indices of RV systolic and diastolic function were unchanged between in-exercise assessment points. Neither pulmonary artery pressures (26 ± 9 mmHg vs 17 ± 10 mmHg, P > 0.05) nor RV wall stress (7.1 ± 3.0 vs 6.2 ± 2.4, P > 0.05) were significantly elevated during exercise. Despite this, post-exercise measurements revealed RV dilation (increased RVD1 and 3), and reduced RV global strain (- 21.2 ± 3.5 vs - 23.8 ± 2.3, P = 0.0168) and diastolic tissue velocity (13.8 ± 2.5 vs 17.1 ± 3.4, P = 0.019) vs pre-exercise values. CONCLUSION: A 6 h cycling exercise bout at 75% maximum heart rate did not alter RV structure, systolic or diastolic function assessments during exercise. Pulmonary artery pressures are not elevated beyond normal limits and therefore RV afterload is unchanged throughout exercise. Despite this, there is some evidence of RV dilation and altered function in post-exercise measurements.

Contrast echocardiography: a practical guideline from the British Society of Echocardiography.

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

Comparison of echocardiographic methods for calculating left ventricular mass in elite rugby football league athletes and the impact on chamber geometry.

Background: Recommendations for the echocardiographic assessment of left ventricular (LV) mass in the athlete suggest the use of the linear method using a two-tiered classification system (2TC). The aims of this study were to compare the linear method and the area-length (A-L) method for LV mass in elite rugby football league (RFL) athletes and to establish how any differences impact the classification of LV geometry using 2TC and four-tier (4TC) classification systems. Methods: Two hundred and twenty (220) male RFL athletes aged 25 ± 5 (14-34 years) were recruited. All athletes underwent echocardiography and LV mass was calculated by the American Society of Echocardiography (ASE) corrected Linear equation (2D) and the A-L method. Left ventricular mass Index (LVMi) was used with relative wall thickness to determine geometry in the 2TC and with concentricity and LV end diastolic volume index for the 4TC. Method specific recommended cut-offs were utilised. Results: Higher values of absolute (197 ± 34 vs. 181 ± 34 g; p < 0.0001) and indexed (92 ± 13 vs. 85 ± 13 g/m2; p < 0.0001) measures of LV mass were obtained from A-L compared to the linear method. Normal LV geometry was demonstrated in 98.2% and 80% of athletes whilst eccentric hypertrophy in 1.4% and 19.5% for linear and A-L respectively. Both methods provided 0.5% as having concentric remodelling and 0% as having concentric hypertrophy. Allocation to the 4TC resulted in 97% and 80% with normal geometry, 0% and 8.6% with eccentric dilated hypertrophy, 0% and 7.7% with eccentric non-dilated hypertrophy, 1.4% and 0.5% with concentric remodelling and 1.4% and 3% with concentric non-dilated hypertrophy for linear and A-L methods respectively. No participants had concentric dilated hypertrophy from either methods. Conclusion: The linear and A-L method for calculation of LV mass in RFL athletes are not interchangeable with significantly higher values obtained using A-L method impacting on geometry classification. More athletes present with eccentric hypertrophy using 2TC and eccentric dilated/non-dilated using 4TC. Further studies should be aimed at establishing the association of A-L methods of LV mass and application of the 4TC to the multi-factorial demographics of the athlete.

The athlete's heart: insights from echocardiography.

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.

Seasonal variation of cardiac structure and function in the elite rugby football league athlete.

BACKGROUND: Pre-participation cardiac screening (PCS) of "Super-League" rugby football league (RFL) athletes is mandatory but may be completed at any time point. The aim of this study was to assess cardiac electrical, structural and functional variation across the competitive season. METHODS: Elite, male, RFL athletes from a single Super-League club underwent cardiac evaluation using electrocardiography (ECG), 2D echocardiography and speckle tracking echocardiography (STE) at four time points across the RFL season; (1) End pre-season (ENDPRE), (2) mid-season (MIDCOMP), (3) end-season (ENDCOMP) and (4) End off-season (ENDOFF). Training loads for each time point were also determined. One-way ANOVA with post-hoc Bonferroni were used for statistical analyses. RESULTS: Total workload undertaken by athletes was lower at both MIDCOMP and ENDCOMP compared to ENDPRE (P < 0.001). ECG patterns were normal with training-related changes that were largely consistent across assessments. Structural data did not vary across assessment points. Standard functional data was not different across assessment points but apical rotation and twist were higher at ENDPRE (9.83˚ and 16.55˚, respectively compared to all other time points (MIDCOMP, 6.13˚ and 12.62˚; ENDCOMP, 5.84˚ and 12.12˚; ENDOFF 6.60˚ and 12.35˚). CONCLUSIONS: Despite some seasonal variation in training load, the athletes' ECG and cardiac structure were stable across a competitive season. Seasonal variation in left ventricular (LV) apical rotation and twist, associated with higher training loads, should be noted in the context of PCS.

Three-Dimensional-Derived Echocardiographic Left Ventricular Structure and Function and Indices from the 12-Lead Electrocardiogram across the Menstrual Cycle in Healthy Physically Active Females: An Exploratory Study.

Background: The impact of the menstrual phases on left ventricular (LV) structure and function using 3D echocardiography and resting electrocardiogram (ECG) in healthy, eumenorrheic, and physically active females has not been investigated. Methods: sixteen females (20 y ± 2) underwent 3D echocardiography and an ECG at three time points in the menstrual cycle phases (follicular, ovulation, luteal). LV end-diastolic volume (LVEDVi), LV ejection fraction (LVEF), LV mass allometrically indexed to height2.7 (LVMi), torsion, and global longitudinal, circumferential, and radial strain (GLS, GCS, and GRS) were evaluated. ECG data of the P and QRS waves were presented as well as axis deviation, chamber enlargement, and any rhythm abnormalities. Results: LVMi was significantly higher in the luteal phase (36.4 g/m2.7 ± 3.3) compared to the follicular (35.0 g/m2.7 ± 3.7) and ovulation (34.7 g/m2.7 ± 4.3) phases (p = 0.026). There were no differences in other indices of LV structure and function or ECG variables across all phases of the menstrual cycle or evidence of arrhythmia. Conclusions: In physically active females, there is a small but significantly higher LVMi associated with the luteal phase of the menstrual cycle with no concomitant change in LV function or ECG parameters. These findings are important to consider when conducting clinical or research serial assessments.

British Society of Echocardiography guideline for the transthoracic echocardiographic assessment of cardiac amyloidosis.

These guidelines form an update of the BSE guideline protocol for the assessment of restrictive cardiomyopathy (Knight et al. in Echo Res Prac, 2013). Since the original recommendations were conceived in 2013, there has been an exponential rise in the diagnosis of cardiac amyloidosis fuelled by increased clinician awareness, improvements in cardiovascular imaging as well as the availability of new and effective disease modifying therapies. The initial diagnosis of cardiac amyloidosis can be challenging and is often not clear-cut on the basis of echocardiography, which for most patients presenting with heart failure symptoms remains the first-line imaging test. The role of a specialist echocardiographer will be to raise the suspicion of cardiac amyloidosis when appropriate, but the formal diagnosis of amyloid sub-type invariably requires further downstream testing. This document seeks to provide a focused review of the literature on echocardiography in cardiac amyloidosis highlighting its important role in the diagnosis, prognosis and screening of at risk individuals, before concluding with a suggested minimum data set, for use as an aide memoire when reporting.

Concentric and Eccentric Remodelling of the Left Ventricle and Its Association to Function in the Male Athletes Heart: An Exploratory Study.

AIMS: To compare (1) conventional left ventricular (LV) functional parameters, (2) LV peak strain and strain rate and (3) LV temporal strain and strain rate curves in age, ethnicity and sport-matched athletes with concentric, eccentric and normal LV geometry. METHODS: Forty-five male athletes were categorised according to LV geometry including concentric remodelling/hypertrophy (CON), eccentric hypertrophy (ECC) or normal (NORM). Athletes were evaluated using conventional echocardiography and myocardial speck tracking, allowing the assessment of myocardial strain and strain rate; as well as twist mechanics. RESULTS: Concentric remodelling was associated with an increased ejection fraction (EF) compared to normal geometry athletes (64% (48-78%) and 56% (50-65%), respectively; p < 0.04). No differences in peak myocardial strain or strain rate were present between LV geometry groups including global longitudinal strain (GLS; CON -16.9% (-14.9-20.6%); ECC -17.9% (-13.0-22.1%); NORM -16.9% (-12.8-19.4%)), global circumferential strain (GCS; CON -18.1% (-13.5-24.5%); ECC -18.7% (-15.6-22.4%); NORM -18.0% (-13.5-19.7%)), global radial strain (GRS; CON 42.2% (30.3-70.5%); ECC 50.0% (39.2-60.0%); NORM 40.6 (29.9-57.0%)) and twist (CON 14.9° (3.7-25.3°); ECC 12.5° (6.3-20.8°); NORM 13.2° (8.8-24.2°)). Concentric and eccentric remodelling was associated with alterations in temporal myocardial strain and strain rate as compared to normal geometry athletes. CONCLUSION: Physiological concentric and eccentric remodelling in the athletes heart is generally associated with normal LV function; with concentric remodelling associated with an increased EF. Physiological concentric and eccentric remodelling in the athletes heart has no effect on peak myocardial strain but superior deformation and untwisting is unmasked when assessing the temporal distribution.

Association of left ventricular strain-volume loop characteristics with adverse events in patients with heart failure with preserved ejection fraction.

AIMS: Patients with heart failure with preserved ejection fraction (HFpEF) are characterized by impaired diastolic function. Left ventricular (LV) strain-volume loops (SVL) represent the relation between strain and volume during the cardiac cycle and provide insight into systolic and diastolic function characteristics. In this study, we examined the association of SVL parameters and adverse events in HFpEF. METHODS AND RESULTS: In 235 patients diagnosed with HFpEF, LV-SVL were constructed based on echocardiography images. The endpoint was a composite of all-cause mortality and Heart Failure (HF)-related hospitalization, which was extracted from electronic medical records. Cox-regression analysis was used to assess the association of SVL parameters and the composite endpoint, while adjusting for age, sex, and NYHA class. HFpEF patients (72.3% female) were 75.8 ± 6.9 years old, had a BMI of 29.9 ± 5.4 kg/m2, and a left ventricular ejection fraction of 60.3 ± 7.0%. Across 2.9 years (1.8-4.1) of follow-up, 73 Patients (31%) experienced an event. Early diastolic slope was significantly associated with adverse events [second quartile vs. first quartile: adjusted hazards ratio (HR) 0.42 (95%CI 0.20-0.88)] after adjusting for age, sex, and NYHA class. The association between LV peak strain and adverse events disappeared upon correction for potential confounders [adjusted HR 1.02 (95% CI 0.96-1.08)]. CONCLUSION: Early diastolic slope, representing the relationship between changes in LV volume and strain during early diastole, but not other SVL-parameters, was associated with adverse events in patients with HFpEF during 2.9 years of follow-up.