Abnormal pulmonary venous flow patterns on fetal echocardiography and a nutmeg lung pattern on fetal magnetic resonance imaging are seen in patients with pulmonary venous stenosis. The association between these findings and the degree of pulmonary venous stenosis remains unknown. We report an extremely rare case of a fetus diagnosed with hypoplastic left heart syndrome complicated by an absent atrial septum and supracardiac total anomalous pulmonary venous connection with left pulmonary venous congestion. This case suggests that compared to non-pulsatile continuous pulmonary venous flow, the nutmeg lung pattern can only be observed with severe pulmonary congestion and advanced pulmonary lymphangiectasia.

BACKGROUND: Systemic thromboembolism is a known complication of rheumatic mitral stenosis (RMS) in sinus rhythm (SR). Left atrial appendage (LAA), the commonest site of thrombus formation is usually hypocontractile (inactive) in such patients. We aimed to study the prevalence of LAA inactivity (LAAI) in severe RMS and assess its independent predictors. METHODS: The study population consisted of 100 patients of severe RMS in sinus rhythm. Transthoracic and transesophageal echocardiography were done to assess LAA contractile function. Patients with LAA-peak emptying velocity <25 cm/sec were defined as having LAAI. RESULTS: The mean age of study subjects was 31.66±8.69 years and 56% were females. 73% patients had LAAI (Group A), while remaining 27% had normal LAA function (Group B). Mitral-valve area (MVA) and lateral annulus systolic velocity (Sa-wave) were significantly lower while mean pressure gradient across mitral valve (MGMV) and serum fibrinogen were significantly higher (all p-values <0.001) in group A patients. On multivariate regression analysis, MGMV (p<0.001), Sa-wave (p=0.02) and serum fibrinogen (p=0.005) were independent predictors of LAAI. Optimal cut-off values of MGMV, Sa-wave and serum fibrinogen for predicting LAAI were 11.5mmHg, 6.8cm/sec and 300mg/dL respectively.67(90.55%) patients in group A compared to 13(48.1%) in group B had LA/LAA smoke. LAAI was the only independent predictor of left atrium (LA)/LAA smoke and associated thrombus. CONCLUSION: There is high prevalence of LAAI in patients of severe MS in SR. MGMV, Sa-wave and serum fibrinogen levels are independent predictors of LAAI. LAAI is an independent predictor of LA/LAA smoke and associated thrombus.

Background: We aim to investigate prognostic effects of carotid strain (CS) and strain rate (CSR) in hypertension. Methods: We prospectively recruited 120 patients being treated for hypertension (65.8 ± 11.8 years, 58% male) in this observational study. Peak circumferential CS and peak CSR after ejection were identified using two-dimensional speckle tracking ultrasound. Major cardiovascular events were any admission for stroke, acute coronary syndrome, and heart failure. Results: After a mean follow-up period of 63.6 ± 14.5 months, 14 (12%) patients had cardiovascular events. Age (75.3 ± 9.2 vs. 64.6 ± 11.6 years; p = 0.001), systolic blood pressure (131.8 ± 15.5 vs. 143.1 ± 16.6 mmHg; p = 0.021), diastolic blood pressure (74.6 ±11.4 vs. 82.1 ± 12.2 mmHg; p = 0.039), use of diuretics (71 vs. 92 %; p = 0.014), carotid CS (2.17 ± 1.02 vs. 3.28 ± 1.14 %; p = 0.001), and CSR (0.28 ± 0.17 vs. 0.51 ± 0.18 1/s; p <0.001) were significantly different between the patients who did and did not reach the end-points. Multivariate Cox regression analysis controlling for age, systolic blood pressure, diastolic blood pressure, and use of diuretics showed that CS (HR 0.425, 95%CI 0.223-0.811, p = 0.009) and CSR (HR 0.001, 95%CI 0.000-0.072, p = 0.001) were independent predictors for cardiovascular events. Conclusion: In conclusions, decreased CS and CSR were associated with cardiovascular events in hypertension.

Objectives: Myocardial injury during active coronavirus disease-2019 (COVID-19) infection is well described however, its persistence during recovery is unclear. We assessed left ventricle (LV) global longitudinal strain (GLS) using speckle tracking echocardiography (STE) in COVID-19 recovered patients and studied its correlation with various parameters.Methods: A total of 134 subjects within 30-45 days post recovery from COVID-19 infection and normal LV ejection fraction were enrolled. Routine blood investigations, inflammatory markers (on admission) and comprehensive echocardiography including STE were done for all. Results: Of the 134 subjects, 121 (90.3%) were symptomatic during COVID-19 illness and were categorized as mild: 61 (45.5%), moderate: 50 (37.3%) and severe: 10 (7.5%) COVID-19 illness. Asymptomatic COVID-19 infection was reported in 13 (9.7%) patients. Subclinical LV and right ventricle (RV) dysfunction were seen in 40 (29.9%) and 14 (10.5%) patients respectively. Impaired LVGLS was reported in 1 (7.7%), 8 (13.1%), 22 (44%) and 9 (90%) subjects with asymptomatic, mild, moderate and severe disease respectively. LVGLS was significantly lower in patients recovered from severe illness (mild: -21 ± 3.4%; moderate: -18.1 ± 6.9%; severe: -15.5 ± 3.1%; P < 0.0001). Subjects with reduced LVGLS had significantly higher interleukin-6 (P < 0.0001), C-reactive protein (P = 0.001), lactate dehydrogenase (P = 0.009) and serum ferritin (P = 0.03) levels during index admission. Conclusions: Subclinical LV dysfunction was seen in nearly a third of recovered COVID-19 patients while 10.5% had RV dysfunction. Our study suggests a need for closer follow-up among COVID-19 recovered subjects to elucidate long-term cardiovascular outcomes.

Objective: Predicting postoperative atrial fibrillation (PoAF) in the preoperative period will provide a serious advantage in preventing the morbidity and mortality associated with this arrhythmia and in planning the treatment. In this study, we investigated the value of atrial electromechanical delay (AEMD) in predicting the development of PoAF. Methods: A total of 93 patients who underwent isolated coronary artery bypass grafting (CABG) operation were included in this prospective study. Patients’ demographic characteristics, laboratory parameters, echocardiographic data, and AEMD durations that could be measured by the co-use of electrocardiography and echocardiography were recorded. The patients at sinus rhythm during the postoperative period were identified as “Group 1”, and those who developed PoAF were identified as “Group 2”. Results: PoAF incidence was 26.88% (n=25). Left ventricle (LV) lateral AEMD, LV medial AEMD, right ventricle lateral AEMD, and left atrium (LA) lateral AEMD durations of Group 2 were significantly higher than Group 1 (p<0.001, p=0.004, p=0.004, p<0.001; respectively). In Univariate Logistic Regression Analysis, the age, hypertension, LA maximum volume, LA lateral AEMD and pulmonary artery pressure were significantly associated with PoAF development (p=0.01, p=0.004, p=0.004, p=0.001, p=0.01; respectively). However, only LA lateral AEMD was found as an independent predictive factor for the development of PoAF in the Multivariate Logistic Regression Analysis (OR:1.03, 95% CI:1,001-1.06, p=0.04). AUC was 0.741 for LA lateral AEMD in ROC Curve Analysis (95% CI:0.633-0.849, p<0.001). Conclusions: The development of PoAF can be predicted by AEMD durations measured in the preoperative period in patients undergoing isolated CABG.

Objective: Arterial stiffness refers to arterial wall rigidity, particularly in central vessels, and is an independent predictor of cardiovascular disease. 25-Hydroxy (OH) vitamin D has beneficial effects on blood pressure, vascular endothelial function, and arterial stiffness. Therefore, we aimed to elucidate the role of 25-OH vitamin D deficiency in arterial stiffness development and its relationship with arterial stiffness in healthy children. Methods: This study included 80 patients with low levels of 25-OH vitamin D and 40 healthy control. The study participants were then divided into three groups: group 1 consisted of patients with a deficient 25-OH D level of < 19.9 ng/mL, group 2 with an insufficient 25-OH D level between 20-29.9 ng/mL; group 3 were considered control group with a sufficient serum 25-OH vitamin D level of ≥30 ng/mL. Aortic strain, distensibility, stiffness index, and standard left ventricular measurements were calculated using M-mode echocardiographic data. Results: Left ventricular mass index (LVMI) and interventricular septal diastolic thickness (IVSTd) appeared to increase in group 1 compared to groups 2 and 3. Aortic strain and distensibility were significantly decreased in group 1, whereas aortic stiffness index and elastic modulus were significantly increased. The aortic stiffness index was negatively correlated with serum 25-OH vitamin D levels; however, aortic strain, aortic distensibility, and LVMI were positively correlated. Conclusions: Our study results revealed a significant relationship between 25-OH vitamin D levels indicative of a deficiency and aortic stiffness. We suggest that arterial stiffness may also occur in healthy children with a 25-OH vitamin D deficiency.

Aortico-left ventricular tunnel (ALVT) is a rare congenital cardiac anomaly and constitues of less than 0.1% of all congenital cardiac defects (1). ALVT is described as an abnormal connection between the ascending aorta and the left ventricul which originates commonly above the right sinus of valsalva. Most patients are diagnosed with an ALVT during early infancy (2). Although transthoracic echocardiography (TTE) is more effective in diagnosis of ALVT, misdiagnosis rate was 17.1% (3). Sinus of valsalva aneurysm (SVA) is frequently confused with ALVT (3). We report a term female newborn with SVA in echocardiographic examination but in surgery she was diagnosed with ALVT.

A congenital left atrial appendage aneurysm (LAAA) is a rare cardiac malformation that is usually diagnosed in adulthood. It is rarely diagnosed prenatally. In most cases, surgical resection is recommended soon after the diagnosis has been made due to the risk of arrhythmia and thrombotic events. The present report describes a case of LAAA which was prenatally diagnosed and was asymptomatic postnatally. Imaging revealed the relation of the cardiac and airway structures around the LAAA in detail. The patient underwent surgical resection of the LAAA successfully at 7 months of age and is currently healthy at 5 years of age.

Extramedullary involvement of the endocardium is rare in multiple myeloma. Here we describe a case of multiple myeloma (plasma cell) with extramedullary plasmablastic transformation and endocardial involvement, which resulted in partial superior vena cava obstruction. We also conducted a literature review and summary analysis of space-occupying lesions in the heart in 12 patients with multiple myeloma (including the current case) in the last 10 years. Echocardiography is the preferred radiologic examination method for diagnosis and follow-up in multiple myeloma, and surgical resection is effective for alleviating symptoms.

Prevalence of primary coronary cameral fistula (CCF) is extremely rare, especially for CCF with the drainage site into the left ventricle. We describe a 45-year-old patient with chest tightness in whom a giant aneurysm associated with proximal right coronary artery (RCA), and the distal end of RCA terminated into the left ventricle through a fistula was discovered by echocardiography. Dual-source computer tomography revealed the CCF-related giant RCA aneurysm. The drainage site and coexistent abnormality could not be visualized well by coronary artery angiography because of the severely diluted contrast medium into the aneurysm. Finally, the patient received surgical treatment and is asymptomatic now.

Intraprocedural transesophageal echocardiography (TEE) guidance plays an essential role in transcatheter repair therapy of the tricuspid valve (TV). So far, several different imaging concepts are in use. However, an imaging protocol that fully addresses the morphological complexity of the TV and further offers efficacious workarounds for the frequently occurring restrictions of TV imaging is still missing. As a tertiary referral center with a large experience of more than 250 cases of transcatheter edge-to-edge repair (TEER) of the TV performed at the Heart Valve Center in Mainz/Germany, we have constantly adapted our periinterventional echocardiographic approach to accomplish both. As a key measure for success, we intensely rely on the transgastric acoustic windows that not only delivers high-resolution information on the morphology of the TV and all relevant procedural steps but also help to avoid the frequent shadowing artefacts experienced in transesophageal imaging.

Background Timing of aortic valve intervention is dependent on the accuracy and reproducibility of echocardiographic (ECHO) parameters. We aimed to assess haemodynamic subsets of aortic stenosis (AS), their change over time, and variability of ECHO parameters. Method This retrospective, longitudinal study compared sequential ECHO over 15 months to identify concordant or discordant aortic valve area (AVA) and mean pressure gradient (MPG). Results We included 143 patients with a mean age of 76.0 years. The median length of time between studies was 112 days (IQR 38-208). Initially participants were classified as 10 (7.0%) mild, 49 (34.3%) moderate and 84 (58.7%) severe AS. In 80 (55.9%) AVA and MPG were concordant; stroke volume index (SVi) was <35ml/m2 in 53 (74.6%). AS severity was downgraded in 33 (23.1%) patients. MPG was most consistent and AVA was the least consistent between successive investigations (intraclass correlation coefficients R=0.86 and R=0.76, respectively). Even small variations in left ventricular outflow tract (LVOT) measurement of 1 standard deviation reclassified up to 67% of participants from severe to non-severe. Conclusion Almost half of patients with AS have valve area/gradient discordance. Variations in LVOT diameter measurement commensurate with clinical practice reclassified AS severity in up to 2/3 of cases. Change in AS severity should only be accepted following careful scrutiny of all available ECHO data.

Background: Identification of elevation in pulmonary pressures during exercise may provide prognostic and therapeutic implications in patients with connective tissue disease (CTD). Interstitial lung disease (ILD) is common in CTD patients and subtle interstitial abnormalities detected by lung ultrasound could predict exercise-induced pulmonary hypertension (PH). Methods and Results: Echocardiography and lung ultrasound were performed at rest and bicycle exercise in CTD patients (n=41) and control subjects without CTD (n=24). Ultrasound B-lines were quantified by scanning four intercostal spaces in the right hemithorax. We examined the association between total B-lines at rest and the development of exercise-induced PH during ergometry exercise. Compared to controls, the number of total B-lines at rest was higher in CTD patients (0 [0, 0] vs. 2 [0, 9], p<0.0001) and was correlated with radiological severity of ILD assessed by computed tomography (fibrosis score, r=0.70, p<0.0001). Pulmonary artery systolic pressure (PASP) was increased with ergometry exercise in CTD compared to controls (48±14 vs. 35±13 mmHg, p=0.0006). The number of total B-lines at rest was highly correlated with higher PASP (r=0.52, p<0.0001) and poor right ventricular pulmonary artery coupling (tricuspid annular plane systolic excursion/PASP ratio, r=-0.31, p=0.01) during peak exercise. The number of resting B-lines predicted the development of exercise-induced PH with an area under the curve 0.79 (p=0.0003). Conclusions: These data may suggest the value of a simple resting assessment of lung ultrasound as a potential tool for assessing the risk of exercise-induced PH in CTD patients.

Aims: The purpose of this study was to examine cardiac structure and function in lowlanders at high altitude(HA) to investigate short-term adaptation and long-term cardiac remodeling. Methods: In total of 301 healthy subjects included in this study, short-term exposed (STE) and acclimatized lowlanders (AL) at HA, native Tibetans(NT) and sea level residents(SLR) were comprised of 75,77,69 and 80 participants, respectively. Standard echocardiography was performed on all groups, subjects at HA were examined after return to sea level in <24 hours. Results: SBP and HR did not increase significantly after short-term exposure to HA in STE, but increased after long-term exposure in AL, which could be detected even after returning to the plain. Exposure to HA enlarged right heart, widened pulmonary artery and reduced left ventricular(LV) diastolic function in lowlanders. The degree of diastolic dysfunction was more obvious in AL. LV wall thickness increased even after short-term exposure to HA in lowlanders. Ejection fraction did not change significantly in STE, but decreased in AL. Conclusions: Exposure to HA could enlarged the right heart and decrease the diastolic function of LV in lowlanders. The LV systolic function was preserved after short-term HA exposure, but decreased after long-term HA exposure.

Methods The study included 59 patients with normal fetal heart structure, blood flow, and heart rhythm (fetal abnormality-negative group) and 50 patients with abnormal fetal heart structure, blood flow, and/or heart rhythm (fetal abnormality-positive group). aCMQ was performed in both groups to obtain left and right ventricular endocardial global longitudinal strain (GLSendo), mid-myocardial global longitudinal strain (GLSmid), and epicardial global longitudinal strain (GLSepi). Parameters between the two groups were compared and correlation analyses performed. A deformation analysis was performed by two trained observers, and reproducibility was assessed. Results The fetal left ventricular and right ventricular global longitudinal strain (LV-GLS and RV-GLS, respectively) decreased in a gradient from the endocardium to the epicardium. LV-GLS and RV-GLS of all myocardial layers were lower in the fetal abnormality-positive than -negative group (all P<0.05). Correlation analysis showed that neither LV-GLS nor RV-GLS was significantly correlated with gestational age in the fetal abnormality-negative group (all P>0.05), whereas left ventricular GLSendo, GLSmid, and GLSepi were negatively correlated with gestational age in the fetal abnormality-positive group (r=−0.39 to −0.44, all P<0.05). Repeatability testing showed that the inter-observer and intra-observer intraclass correlation coefficients for LV-GLS and RV-GLS in each myocardial layer were >0.75 (all P<0.001). Conclusions As a new speckle tracking echocardiography tool, aCMQ has feasibility and repeatability in evaluating myocardial deformation of the fetal ventricle. This technique might provide helpful information on ventricular myocardial deformation in fetal hearts with abnormal structure or rhythm for clinical guidance in pregnancy.

Double chambered left ventricle is an exceedingly rare congenital anomaly. We report a case diagnosed prenatally at 24 weeks of gestation and its postnatal evolution to left ventricular dysfunction.

Aims. Right ventricular (RV) dysfunction is a predictor of adverse outcomes among patients with HF with reduced ejection fraction (HFrEF) however, differences in RV parameters in HFrEF patients with ischemic (ICM) and non-ischemic cardiomyopathies (NICM) are not well understood. We investigated echocardiographic characteristics, including RV strain, in patients with acute decompensated heart failure (ADHF) and compared patients with ICM and NICM etiology. Methods. Consecutive patients who presented with ADHF and NYHA class III-IV were prospectively enrolled if they had LVEF <40% and history of ICM or NICM. All patients underwent clinical exam, laboratory evaluation and 2-D echocardiographic assessment of the left ventricular (LV) and RV function, LV and RV global longitudinal strain (LVGLS, RVGLS), and RV free wall strain (RVfwLS). Results. Of 84 patients, 44 had ICM and 40 NICM. The groups had similar blood pressure, NT-proBNP, and echocardiographic parameters of LV function including LVGLS. Absolute RVGLS values were lower than RVfwLS values in both groups. Patients with NICM had significantly lower RVfwLS, but not RVGLS, compared to patients with ICM (-13% to -17%, P=0.006). Similar differences in RVfwLS were seen in patients in NYHA class III (NICM vs ICM: -13% and -17%, respectively, 95% CI: -8.5 to -0.5) and NYHA class IV (NICM vs ICM: -13.8% and -17%, respectively, 95% CI: -6.4 to -0.59). Conclusion. Among patients hospitalized with ADHF, patients with nonischemic etiology compared with the patients with ICM, have worse RV dysfunction measured by RVfwLS, despite similar extent of LV impairment and the same functional limitation class.

Objective: To evaluate early changes in left ventricular systolic function in patients with systemic lupus erythematosus (SLE) using three-dimensional speckle tracking imaging (3D-STI). Methods: Thirty SLE patients and 30 healthy people (control group) were selected, the patients were further divided into subgroups according to their Safety of Estrogens in Lupus Erythematosus National Assessment version of the SLE Disease Activity Index (SELENA-SLEDAI) score: SELENA-SLEDAI ≤ 12 (mild-to-moderate group), SELENA-SLEDAI > 12 (severe group). Blood samples were obtained from patients and laboratory investigations were performed. All participants were examined using 3D-STI, the 3D conventional and strain parameters were obtained. The above parameters were compared in the three studied groups. Receiver operating curves (ROC) were prepared for above parameters and analyzed to identify correlations among LVEF, GLS, GCS, LVtw, Tor, MCI and hs-TropT. Results: Compared with the control group, the absolute values of LVEDV, LVEF, GLS, GCS, LVtw, Tor and MCI decreased, LV EDmass, LV ESmass and PSD increased in the mild-to-moderate and the severe groups (P2 < 0.05, P3 < 0.05). There was statistically significant difference in terms of strain parameters between the mild-to-moderate group and the severe group (P1 < 0.05). The highest area under the ROC for MCI was 0.909, the highest sensitivity for MCI was 90.00%, and the highest specificity for Tor was 86.67%. Correlation analysis showed that there was a good correlation between the MCI and hs-TropT (r = − 0.677). Conclusion: 3D-STI technology may help detect early changes in left ventricular systolic function in patients with SLE