Journal of the American Society of Echocardiography - Articles in Press

Usefulness of the Right Parasternal Approach to Evaluate the Morphology of Atrial Septal Defect for Transcatheter Closure Using Two-Dimensional and Three-Dimensional Transthoracic Echocardiography - Corrected Proof

2012-01-30

Background: The aim of this study was to demonstrate the feasibility and usefulness of addition of the right parasternal approach to the conventional left parasternal and apical approaches using two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography (TTE) for morphologic evaluation in cases of transcatheter closure of atrial septal defects (ASDs).Methods: In 112 consecutive patients with ASDs, the morphology of the defects was evaluated for transcatheter closure in the right parasternal view in addition to the conventional left views using 2D and 3D TTE. Measurements of the maximal ASD diameter and detection of deficient rim obtained on 2D TTE were compared with those obtained by 2D transesophageal echocardiography. The shapes and locations of ASDs visualized by 3D TTE were compared with those visualized by 3D transesophageal echocardiography.Results: In 88 patients (80.0%), optimal images from the right parasternal approach for morphologic evaluation of ASDs were obtained. Although there was a significant difference in maximal ASD diameter obtained only in the conventional left approach compared with transesophageal echocardiographic measurements (P < .05), when the right parasternal approach was applied, a significant difference was not found (P = .18), and the diagnostic concordance of the rim deficiency was improved from 85.2% to 90.9%. Three-dimensional TTE from the right parasternal approach improved visualization of the shape and location of ASDs from 65.5% to 74.5%.Conclusions: Additional use of the right parasternal approach enables detailed morphologic evaluation for transcatheter closure of ASDs. In patients with suboptimal images on 3D TTE in the left conventional approach, additional 3D TTE in the right parasternal approach can improve the feasibility of obtaining optimal 3D images to evaluate the shapes and locations of ASDs.

Neonatologists and Echocardiography: Time to Move On - Corrected Proof

Luc Mertens, ASE Writing Group on Targeted Neonatal Echocardiography — 2012-01-30

We thank Dr. Sinha and colleagues for their interest in our recently published recommendations on targeted neonatal echocardiography (TNE). The authors nicely explain the way they developed a TNE service at the Boston Medical Center. This can serve as an example of how our practice guidelines can be implemented by neonatal intensive care units (NICU). Organizing a 24-hour service 7 days a week is an important challenge for most units, which should not be underestimated when starting a TNE program. Therefore, collaborating with existing resources has obvious logistic advantages. Wherever possible, this implies maximal integration within existing echocardiography services. As Sinha et al. correctly state, this integrated model also influences the quality of care and improves the safety of the TNE service. For NICUs in hospitals without pediatric cardiology services, telemedicine links are a good solution. This can consist of the transfer of images to a referral center, as in the Boston approach, or of more advanced solutions, such as a live-scanning approach with trained neonatologists scanning under remote supervision of pediatric cardiologists. This uses Internet transmission with a two-screen device, one connected to the ultrasound machine on site and the second to a camera observing the operator. This allows the reviewing physician to provide direct instructions to the operator while scanning. The success of a TNE program is critically dependent on the training of the operators. We agree with Sinha et al. that echocardiographic training of neonatologists should go beyond informal self-directed learning, and we hope that our more formal extensive training model will improve operators’ diagnostic skills.

Prevalence and Mechanism of Tricuspid Regurgitation following Implantation of Endocardial Leads for Pacemaker or Cardioverter-Defibrillator - Corrected Proof

Maha A. Al-Mohaissen, Kwan Leung Chan — 2012-01-27

Endocardial lead–induced tricuspid regurgitation has not been well recognized, either clinically or echocardiographically, and yet it is likely a preventable iatrogenic disease. In severe cases, it can lead to right ventricular failure and require tricuspid valve surgery. This complication will become increasingly important, because the numbers of permanent pacemakers and implantable cardioverter-defibrillators are expected to increase because of the aging population and the expanding capabilities of these devices. Published studies are largely retrospective, and serial studies to assess the time course of the development of tricuspid regurgitation are lacking. The mechanisms and severity of tricuspid regurgitation may not be well evaluated by two-dimensional echocardiography. Real-time three-dimensional echocardiography appears to be a promising technique to evaluate the mechanism of tricuspid regurgitation and may allow the early detection of patients who will develop severe lead-induced tricuspid regurgitation. A better understanding of the mechanism of lead-induced tricuspid regurgitation will be essential to the development of preventive strategies, which can then be tested in future clinical trials.

Left Ventricular Noncompaction: A 25-Year Odyssey - Corrected Proof

2012-01-27

Left ventricular noncompaction (LVNC) is a cardiomyopathy associated with sporadic or familial disease, the latter having an autosomal dominant mode of transmission. The clinical features associated with LVNC vary from asymptomatic to symptomatic patients, with the potential for heart failure, supraventricular and ventricular arrhythmias, thromboembolic events, and sudden cardiac death. Echocardiography is the diagnostic modality of choice, revealing the pathognomonic features of a thick, bilayered myocardium; prominent ventricular trabeculations; and deep intertrabecular recesses. Widespread use and advances in the technology of echocardiography and cardiac magnetic resonance imaging are increasing awareness of LVNC, and cardiac magnetic resonance imaging is improving the ability to stage the severity of the disease and potential for adverse clinical consequences. Study of LVNC through research in embryology, imaging, and genetics has allowed enormous strides in the understanding of this heterogeneous disease over the past 25 years.

Factors Affecting the Endothelial Retention of Targeted Microbubbles: Influence of Microbubble Shell Design and Cell Surface Projection of the Endothelial Target Molecule - Corrected Proof

2012-01-24

Background: In biologic systems, the arrest of circulating cells is mediated by adhesion molecules projecting their active binding domain above the cell surface to enhance bond formation and tether strength. Similarly, molecular spacers are used for ligands on particle-based molecular imaging agents. The aim of this study was to evaluate the influence of tether length for targeting ligands on ultrasound molecular imaging agents.Methods: Microbubbles bearing biotin at the end of variable-length polyethylene glycol spacer arms (MB2000 and MB3400) were prepared. To assess in vivo attachment efficiency to endothelial counterligands that vary in their distance from the endothelial cell surface, contrast-enhanced ultrasound (CEU) molecular imaging of tumor necrosis factor–α–induced P-selectin (long distance) or intercellular adhesion molecule–2 (short distance) was performed with each agent in murine hind limbs. To assess the influence of the glycocalyx on microbubble attachment, CEU molecular imaging of intercellular adhesion molecule–2 was performed after degradation of the glycocalyx.Results: CEU molecular imaging targeted to P-selectin showed signal enhancement above control agent for MB2000 and MB3400, the degree of which was significantly higher for MB3400 compared with MB2000. CEU molecular imaging targeted to intercellular adhesion molecule–2 showed low overall signal for all agents and signal enhancement above control for MB3400 only. Glycocalyx degradation increased signal for MB3400 and MB2000.Conclusions: Microbubble targeting to endothelial ligands is influenced by (1) the tether length of the ligand, (2) the degree to which the endothelial target is projected from the cell surface, and (3) the status of the glycocalyx. These considerations are important for designing targeted imaging probes and understanding potential obstacles to molecular imaging.

Interaction between Myocardial and Vascular Changes in Obese Children: A Pilot Study - Corrected Proof

2012-01-24

Background: Changes in vascular and myocardial structure and function have been demonstrated in obese children, but limited data are available on how these changes are related. The aims of this study were to investigate vascular and myocardial changes in obese children with lipid abnormalities and to study the interactions between vascular and myocardial parameters.Methods: A cross-sectional, prospective observational study was conducted. Twenty-one obese and 27 normal-weight controls aged 14 ± 2 years participated. Cardiac assessment included geometric parameters and myocardial deformation (strain and strain rate) analysis by color tissue Doppler and speckle-tracking echocardiography. Vascular assessment included carotid intima-media thickness, flow-mediated dilatation, pulse-wave velocity, and other stiffness measures of the aorta and carotid artery, as well as noninvasive estimation of arterial elastance and left ventricular (LV) end-systolic elastance.Results: Obese children compared with controls had lower color tissue Doppler–derived LV systolic radial strain values (45 ± 11% vs 56 ± 12%, P = .002), lower speckle-tracking echocardiography–derived LV systolic longitudinal strain values (−18 ± 2% vs −21 ± 2%, P < .001), and lower speckle-tracking echocardiography–derived LV early diastolic strain rate values (1.7 ± 0.3 vs 2.5 ± 0.4, P < .001). Carotid intima-media thickness was increased, pulse-wave velocity was faster, and arterial distension coefficients were lower in obese children. The ratio of arterial elastance to LV end-systolic elastance (a marker of ventricular-arterial coupling) was lower in obese children than controls (0.73 ± 0.32 vs 0.47 ± 0.15, P = .003). Changes in vascular parameters were correlated with changes in longitudinal myocardial deformation parameters.Conclusions: Obese children with lipid abnormalities have reduced systolic and diastolic LV deformation characteristics, early vessel wall changes, and increased arterial stiffness. Abnormal ventricular-vascular interaction is suggested by these data and warrants further investigation.

Assessment of Left Atrial Mechanics in Patients with Atrial Fibrillation: Comparison between Two-Dimensional Speckle-Based Strain and Velocity Vector Imaging - Corrected Proof

2012-01-24

Background: Two-dimensional (2D) speckle tracking–derived left atrial (LA) strain (ε) facilitates comprehensive evaluation of LA contractile, reservoir, and conduit function; however, its dependence on the individual software used for assessment has not been evaluated. The aim of this study was to compare LA ε derived from two different speckle-tracking software technologies, Velocity Vector Imaging (VVI) and 2D speckle-tracking echocardiography (STE).Methods: VVI-derived and 2D STE–derived global longitudinal LA ε and ε rate (SR) were directly compared in 127 patients (mean age, 62 ± 10 years) with atrial fibrillation. Peak negative, peak positive, and total ε (corresponding to LA contractile, conduit, and reservoir function) were measured during sinus rhythm. Late negative (LA contraction), peak positive (left ventricular systole), and early negative (left ventricular early diastole) SR were also measured.Results: The measurement of LA ε and SR by both software was feasible in high proportions of patients (93% with VVI and 93% with 2D STE). The average analysis of εnegative was −7.24 ± 3.87% by VVI and −7.30 ± 3.37% by 2D STE (P = .84). The average analysis of εpositive was 14.52 ± 5.82% by VVI and 10.74 ± 4.51% by 2D STE (P < .01). The average analysis of εtotal was 21.76 ± 7.39% by VVI and 18.04 ± 5.98% by 2D STE (P < .01). VVI-derived and 2D STE–derived εpositive, εnegative, and εtotal had good correlations with one another (R = 0.79, R = 0.75, and R = 0.80), with low mean differences. Late negative, peak positive, and early negative SR were correlated less well (R = 0.78, R = 0.71, and R = 0.67).Conclusions: LA ε measurement using both VVI and 2D STE is feasible in a large proportion of patients in clinical practice. VVI and 2D STE provide comparable LA ε and SR measurements for LA contractile function.

Reliability and Accuracy of Echocardiographic Right Heart Evaluation in the U.S. Melody Valve Investigational Trial - Corrected Proof

2012-01-24

Background: Appropriate patient selection for transcatheter pulmonary valve (TPV) replacement requires accurate evaluation of right ventricular (RV) performance. The aim of this study was to evaluate the reliability and accuracy of echocardiography for evaluating RV parameters in patients in the five-center Melody TPV trial.Methods: Echocardiographic data were compared with cardiac magnetic resonance (CMR) and catheterization; interobserver comparisons were made using site and core laboratory data.Results: Doppler echocardiographic assessments of RV outflow tract obstruction and RV pressure showed excellent interobserver agreement; mean Doppler gradients were correlated most closely with gradients at catheterization (R = 0.66), and Doppler RV pressure estimates were correlated well with catheterization data (R = 0.58). Assessment of pulmonary regurgitation (PR) using a three-point severity scale showed good agreement with CMR-derived PR fraction (86%). The tricuspid annular Z score was highly reproducible but correlated weakly with CMR RV end-diastolic volume (R = 0.21). However, RV apical diastolic area was highly reproducible (R = 0.87) and had an excellent correlation with CMR RV end-diastolic volume (R = 0.78); all patients with indexed RV apical diastolic areas ≥30 cm2/m2 had CMR RV end-diastolic volumes ≥160 mL/m2. RV function using the fractional area change method showed a fair correlation with CMR RV ejection fraction (R = 0.48).Conclusions: In patients with dysfunctional RV outflow tract conduits, echocardiography provided reproducible, accurate estimates of pressure overload and RV size. Echocardiographic assessment of PR correlated less closely with CMR PR fraction but showed good categorical agreement; assessment of RV function by these methods was suboptimal. Echocardiography alone may be a suitable screening test for some TPV replacement candidates; CMR may be indicated for TPV replacement decisions hinging on assessment of RV function.

Prognostic Value of Tricuspid Annular Tissue Doppler Velocity in Heart Failure with Atrial Fibrillation - Corrected Proof

2012-01-16

Background: Right ventricular function is associated with long-term outcomes of heart failure (HF), particularly with atrial fibrillation (AF). The aim of this study was to evaluate the prognostic value of Doppler tissue imaging at the mitral and tricuspid annuli in patients with HF and AF.Methods: In this prospective observational study, 457 patients (mean age, 67 years; 283 men) referred for HF with AF were enrolled and underwent conventional echocardiography including pulsed-wave Doppler tissue imaging. Systolic (s′) and early diastolic (e′) velocities of the tricuspid and mitral annuli were recorded from the apical four-chamber view. The development of clinical adverse events during the follow-up period was defined as the composite of cardiac death and readmission for HF.Results: During the follow-up period (median, 20 months), 37 patients reached the primary end point (nine deaths and 28 cases of HF). Patients with cardiac events were significantly older and more often had previous HF admissions and diuretic use, higher New York Heart Association classes, and greater average ratios of peak early diastolic mitral inflow to annular velocity. Additionally, Doppler tissue imaging of s′ and e′ at the tricuspid, septal, and lateral mitral annuli were all reduced. Multivariate analysis showed that tricuspid s′ and septal e′ remained significant predictors of cardiac events. By Kaplan-Meier analysis, the occurrence of cardiac events was more frequent when tricuspid s′ was <9.0 cm/sec (P < .001) and when septal e′ was <7.3 cm/sec (P < .001).Conclusions: In patients with HF and AF with a high risk for cardiac events, tricuspid s′ and septal e′ can be independent risk predictors of outcomes.

Aortic Stiffness and Distensibility in Top-Level Athletes - Corrected Proof

2012-01-16

Background: Although cardiac adaptation to different sports has been extensively described, the potential relationship of training with aortic root (AR) elastic properties and diameters in top-level athletes remains not fully investigated. The aims of this study were to compare AR morphology and stiffness between highly trained athletes and sedentary subjects and to assess the independent determinants of AR stiffness and distensibility in athletes.Methods: Four hundred ten elite athletes (220 endurance-trained athletes [ATE] and 190 strength-trained athletes [ATS]; 290 men; mean age, 28.3 ± 13.6 years; age range, 18–40 years) and 240 healthy controls underwent standardized comprehensive transthoracic echocardiography, including Doppler studies. End-diastolic AR diameters were measured at four locations: the aortic annulus, the sinuses of Valsalva, the sinotubular junction, and the maximal diameter of the proximal ascending aorta. The aortic distensibility index was calculated as 2 × (systolic proximal ascending aortic diameter − diastolic proximal ascending aortic diameter)/(diastolic proximal ascending aortic diameter) × (pulse pressure) (cm−2 · dyn−1 · 10−6). AR stiffness index was defined as (systolic blood pressure/diastolic blood pressure)/(systolic proximal ascending aortic diameter − diastolic proximal ascending aortic diameter)/diastolic proximal ascending aortic diameter. Analysis of variance was performed to evaluate differences among groups.Results: Left ventricular (LV) mass index did not significantly differ between the two groups of athletes but was lower in controls. ATS showed higher body surface area, sum of wall thickness (septum plus LV posterior wall), and circumferential end-systolic stress, while LV stroke volume and LV end-diastolic volume were greater in ATE. AR diameters at all levels and AR stiffness were significantly greater in ATS than in ATE and controls, while AR distensibility was significantly higher in ATE. However, AR dilatation was observed only in four male power athletes (1%). By multivariate analyses, in the overall population of athletes, age, LV stroke volume, endurance training, and duration of training were the only independent determinant of higher AR distensibility. On the other hand, age, circumferential end-systolic stress, strength training, and duration of training were independently associated with AR stiffness in ATS.Conclusions: AR diameters and stiffness were significantly greater in strength-trained athletes, while aortic distensibility was higher in endurance athletes compared with age- and sex-matched healthy controls.

The Incremental Value of Valvuloarterial Impedance in Evaluating the Results of Transcatheter Aortic Valve Implantation in Symptomatic Aortic Stenosis - Corrected Proof

2012-01-13

Background: Valvuloarterial impedance (Zva) can estimate the global hemodynamic load on the left ventricle in patients with severe aortic stenosis better than the standard indexes, as shown in previous studies. In fact, Zva can estimate global left ventricular hemodynamic load as the sum of valvular and vascular loads. The aim of this study was to evaluate the acute improvement of left ventricular performance in patients with symptomatic aortic stenosis after transcatheter aortic valve implantation (TAVI) using Zva.Methods: One hundred two consecutive patients who underwent TAVI were submitted to transthoracic echocardiography immediately before and after aortic valve implantation, together with invasive hemodynamic measurements.Results: After TAVI, immediate reductions in the transaortic peak pressure gradient (P < .0001) and mean pressure gradient (P < .0001) and a concomitant increase in aortic valve area (P < .0001) were seen on echocardiography. Left ventricular ejection fraction significantly increased immediately after TAVI in all patients (from 48.9 ± 10.3% to 52.1 ± 11.1%, P < .0001). Regarding global left ventricular hemodynamic load, acute and significant reductions in end-systolic meridional wall stress (from 82.7 ± 42.6 to 57.8 ± 30.1 kdyne · cm−2, P < .0001) and in Zva (from 6.81 ± 2.51 to 5.38 ± 2.13 mm Hg · mL−1 · m−2, P < .0001) were observed. Furthermore, patients who died at 6-month follow-up had higher baseline Zva values compared with those who were alive at 6-month follow-up (8.13 ± 3.08 vs 6.41 ± 2.12 mm Hg · mL−1 · m−2, P < .004).Conclusions: TAVI is characterized by an immediate enhancement of global left ventricular hemodynamic performance, as demonstrated by an acute Zva improvement, even in patients with low baseline ejection fractions.

Ejection Fraction Change and Coronary Artery Disease Severity: A Vasodilator Contrast Stress-Echocardiography Study - Corrected Proof

2012-01-13

Background: An important goal of noninvasive stress testing is the identification of patients with left main coronary artery or three-vessel disease, because coronary artery disease extension and severity are major prognostic factors in ischemic heart disease. Wall motion abnormalities during vasodilator stress echocardiography become apparent in more than one coronary territory only in a small number of patients with multivessel disease. The aim of this study was to assess the value of change in left ventricular ejection fraction change (ΔLVEF) to identify patients with multivessel obstructive coronary artery disease during dipyridamole stress echocardiography.Methods: All dipyridamole stress echocardiographic studies performed at the authors’ institution from October 2007 through March 2010 were retrospectively reviewed, and 150 patients who underwent coronary angiography within the next 60 days were selected. Left ventricular end-diastolic volume and end-systolic volume were measured at baseline and at the end of high-dose dipyridamole; ΔLVEF was calculated as stress ejection fraction minus rest ejection fraction. Patients were divided into four groups (controls and patients with single-vessel, two-vessel, and three-vessel disease) on the basis of coronary angiographic results.Results: The mean LVEF increased significantly from rest to peak stress in all groups except the three-vessel disease group. Mean ΔLVEF was negative in patients with three-vessel or left main coronary artery disease (−2.8 ± 5.1%) and significantly lower compared with all other angiographic groups (10.2 ± 5.1% and 6.2 ± 4.1%, respectively, for single-vessel and two-vessel disease). The negative value of ΔLVEF for three-vessel disease was due mainly to increased end-systolic volume at peak stress. Receiver operating characteristic curves demonstrated excellent accuracy of ΔLVEF compared with change in wall motion score index in identifying patients with multivessel disease, with areas under the curves of 0.96 and 0.62, respectively.Conclusions: ΔLVEF is significantly lower in patients with severe coronary artery disease compared with those with single-vessel or two-vessel disease; reduced ΔLVEF identifies high-risk patients, who are likely to benefit from a more aggressive therapeutic strategy.

In Vitro Atrial Septal Ablation Using High-Intensity Focused Ultrasound - Corrected Proof

2012-01-13

Background: High-intensity focused ultrasound (HIFU) has been applied clinically as a noninvasive therapeutic tool. Atrial septostomy is a palliative treatment for pulmonary artery hypertension. The purpose of this study was to assess the feasibility of atrial septal ablation in vitro using HIFU.Methods: Fourteen sections of atrial septum from pig hearts were treated. Focused ultrasound energy was applied with an operating frequency of 5.25 MHz at the nominal focal point intensity of 4.0 kW/cm2 for 0.4 sec in 1-sec intervals.Results: Lesions were created with ultrasonic exposures ranging from 40 to 120 pulses. There were significant relationships between HIFU exposure time and lesion area on the exposed site (R2 = 0.3389, P < .0001) and lesion volume (R2 = 0.6161, P < .0001).Conclusions: HIFU has the potential to create focal perforations without direct tissue contact. This method may prove useful for noninvasive atrial septostomy.

Validation Study on the Accuracy of Echocardiographic Measurements of Right Ventricular Systolic Function in Pulmonary Hypertension - Corrected Proof

2012-01-10

Background: The accuracy of echocardiographic parameters of right ventricular (RV) function has not been sufficiently validated in patients with pulmonary hypertension (PH). The aim of this study was to evaluate whether echocardiographic measurements reliably reflect RV systolic function in PH using cardiac magnetic resonance imaging (CMRI)–derived RV ejection fraction (RVEF) as a gold standard.Methods: A total of 37 consecutive patients with PH, 20 with pulmonary arterial hypertension, 12 with chronic thromboembolic PH, and five others, were prospectively studied. All patients underwent echocardiography, CMRI, and right-heart catheterization within a 1-week interval. Associations between five echocardiography-derived parameters of RV systolic function and CMRI-derived RVEF were evaluated.Results: All five echocardiography-derived parameters were significantly correlated with CMRI-derived RVEF (percentage RV fractional shortening: r = 0.48, P = .0011; percentage RV area change: r = 0.40, P = .0083; tricuspid annular plane systolic excursion [TAPSE]: r = 0.86, P < .0001; RV myocardial performance index: r = −0.59, P < .0001; and systolic lateral tricuspid annular motion velocity: r = 0.63, P < .0001). Compared with the other indices, TAPSE exhibited the highest correlation coefficient. Of the five echocardiographic measurements, only TAPSE significantly predicted CMRI-derived RVEF in multiple regression analysis (P < .0001). Intraobserver and interobserver reproducibility was favorable for all five indices and was particularly high for TAPSE and systolic lateral tricuspid annular motion velocity.Conclusions: Echocardiographic measurements are promising noninvasive indices of RV systolic function in patients with PH. In particular, TAPSE is superior to other indices in accuracy.

Core Lab Analysis of Baseline Echocardiographic Studies in the STICH Trial and Recommendation for Use of Echocardiography in Future Clinical Trials - Corrected Proof

2012-01-09

Background: The Surgical Treatment for Ischemic Heart Failure (STICH) randomized trial was designed to identify an optimal management strategy for patients with ischemic cardiomyopathy. Baseline echocardiographic examinations were required for all patients. The primary aim of this report is to describe the baseline STICH Echocardiography Core Laboratory data. The secondary aim is to provide recommendations regarding how echocardiography should be used in clinical practice and research on the basis of the experience gained from echocardiography in STICH.Methods: Between September 2002 and January 2006, 2,136 patients with ejection fractions (EFs) ≤ 35% and coronary artery disease amenable to coronary artery bypass grafting were enrolled. Echocardiography was acquired by 122 clinical enrolling sites, and measurements were performed by the Echocardiography Core Laboratory after a certification process for all clinical sites.Results: Echocardiography was available for analysis in 2,006 patients (93.9%); 1,734 (86.4%) were men, and the mean age was 60.9 ± 9.5 years. The mean left ventricular end-systolic volume index, measureable in 72.8%, was 84.0 ± 30.9 mL/m2, and the mean EF was 28.9 ± 8.3%, with 18.5% of patients having EFs > 35%. Single-plane measurements of left ventricular and left atrial volumes were similar to their volumes by biplane measurement (r = 0.97 and r = 0.92, respectively). Mitral regurgitation severity by visual assessment was associated with a wide range of effective regurgitant orifice area, while effective regurgitant orifice area ≥ 0.2 cm2 indicated at least moderate mitral regurgitation by visual assessment. Deceleration time of mitral inflow velocity had a weak correlation with EF (r = 0.25) but was inversely related to estimated pulmonary artery systolic pressure (r = −0.49).Conclusions: In STICH patients with ischemic cardiomyopathy, Echocardiography Core Laboratory analysis of baseline echocardiographic findings demonstrated a wide spectrum of left ventricular shape, function, and hemodynamics, as well as the feasibility and limitations of obtaining essential echocardiographic measurements. It is critical that the use of echocardiographic parameters in clinical practice and research balance the strengths and weaknesses of the technique.

Left Atrial Enlargement Is Associated with a Rapid Decline in Residual Renal Function in ESRD Patients on Peritoneal Dialysis - Corrected Proof

2012-01-06

Background: Left atrial (LA) volume index (LAVI) has been considered a stable indicator of diastolic dysfunction and an independent predictor of mortality in patients with end-stage renal disease. To date, however, little is known about the relationship between LA enlargement and the changes in residual renal function (RRF).Methods: This study was undertaken to investigate the association between LA enlargement and the decline in RRF in 121 incident peritoneal dialysis patients. Within 2 months after the initiation of peritoneal dialysis, LA enlargement was determined by echocardiography and RRF by 24-hour urine collection. Subsequently, RRF was measured every 6 months.Results: The rates of decline in RRF were significantly greater in patients with LA enlargement (LAVI > 32 mL/m2) compared with those without LA enlargement (−0.17 ± 0.18 vs −0.07 ± 0.16 mL/min/month/1.73 m2, P = .002). In a linear mixed model, there was a significant difference in the rates of RRF decline over time between patients with and without LA enlargement (P < .001). Pearson’s correlation analysis revealed that there were significant inverse correlations between the rates of the decline in RRF and LAVI (r = −0.22, P = .018). In multiple linear regression analysis adjusted for other risk factors, LAVI was found to be an independent determinant of the rates of decline in RRF (β = −0.026, P = .018).Conclusions: This study shows that a higher LAVI is independently associated with a more rapid decline in RRF in patients with end-stage renal disease on peritoneal dialysis.

Left Ventricular Diastolic Dysfunction as a Predictor of Rapid Decline of Residual Renal Function in Patients with Peritoneal Dialysis - Corrected Proof

2011-12-26

Background: The aim of this study was to evaluate whether diastolic dysfunction at the start of dialysis could influence renal and cardiovascular survival rates in 82 patients undergoing peritoneal dialysis.Methods: Diastolic dysfunction was determined using left ventricular hypertrophy, the ratio of early peak transmitral inflow velocity to peak diastolic mitral annular velocity (E/E′), and left atrial volume index (LAVI). Residual renal function (RRF) was measured with 24-hour urine collections at baseline (within 1 month of beginning peritoneal dialysis) and thereafter at 6-month intervals for 2 years. To evaluate the long-term prognostic significance of diastolic dysfunction, the 4-year cardiac event–free survival was also evalated.Results: The median slope of RRF decline was −0.07 mL/min/mo/1.73 m2. Forty-five patients (54.9%) with rapid RRF declines (< −0.07 mL/min/mo/1.73 m2) had a higher prevalence of diabetes and eccentric left ventricular hypertrophy, as well as significantly elevated E/E′ ratios and LAVIs. There was a close relationship between baseline E/E′ ratio (r = −0.221, P = .048), LAVI (r = −0.276, P = .015), and RRF decline rate, and both E/E′ > 15 (odds ratio, 3.61; 95% confidence interval, 1.07–12.12) and LAVI > 32 mL/m2 (odds ratio, 3.54; 95% confidence interval, 1.08−11.58) were significant independent predictors of the loss of RRF. Furthermore, E/E′ > 15 also provided additional prognostic value in predicting future cardiac events (hazard ratio, 6.74; 95% confidence interval, 1.07−12.12; P = .023).Conclusions: Left ventricular diastolic dysfunction may be a significant predictor of rapid decline in RRF and adverse cardiac outcomes in patients starting peritoneal dialysis.

Right Ventricular Function with Standard and Speckle-Tracking Echocardiography and Clinical Events in Adults with D-Transposition of the Great Arteries Post Atrial Switch - Corrected Proof

2011-12-26

Background: The prognostic value of deformation parameters of the systemic right ventricle in adults with D-transposition of the great arteries and prior atrial switch has not been reported.Methods: Sixty-four adults with D-transposition of the great arteries and prior atrial switch (mean age, 29 ± 6 years; 22 women; mean right ventricular [RV] fractional area change, 22.9 ± 7.5%; 31 with pacemakers at baseline) and no histories of heart failure or ventricular tachycardia were prospectively evaluated. Global longitudinal strain (GS), global systolic strain rate (GSRs), and global early diastolic strain rate (GSRe) of the right ventricle were measured using speckle tracking from apical views and compared with standard parameters of RV function (fractional area change, tricuspid annular plane systolic excursion, tissue Doppler velocities, and isovolumic acceleration) for association with and potential prediction of clinical events, defined as incident stage C heart failure or ventricular tachycardia.Results: Baseline RV GS, GSRs, and GSRe were −12.5 ± 3.0%, −0.59 ± 0.14 sec−1, and 0.68 ± 0.22 sec−1, respectively. After a median of 2.4 years (interquartile range, 1.5–4.1 years), 12 patients (19%) presented with clinical events (heart failure in 11 patients, ventricular tachycardia in one patient). In Cox models, RV GS had the strongest association with clinical events (hazard ratio [HR] per 1%, 1.35; 95% confidence interval [CI], 1.14–1.58; P < .001), followed by GSRs (HR per 0.01 sec−1, 1.06; 95% CI, 1.02–1.11; P = .006), GSRe (HR per −0.01 sec−1, 1.04; 95% CI, 1.00–1.07; P = .031), and fractional area change (HR per −1%, 1.08; 95% CI, 1.00–1.17; P = .047). Other measures of RV function were not significantly associated with risk for events. In receiver operating characteristic analysis, RV GS ≥ −10% optimally predicted future events (C = 0.83; 95% CI, 0.71–0.91; P < .001).Conclusions: Reduced longitudinal GS of the systemic right ventricle is associated with increased risk for clinical events among patients with D-transposition of the great arteries and prior atrial switch.

Pulmonary Artery Pressure in Young Healthy Subjects - Corrected Proof

2011-12-23

Background: Pulmonary artery systolic pressure (PASP) is frequently measured noninvasively using transthoracic echocardiography. Normal values of PASP are based on studies performed in heterogeneous populations. The normal values of PASP in young healthy subjects are poorly defined. The aim of this study was to describe the distribution and clinical and morphologic correlates of PASP values in young healthy subjects.Methods: Echocardiography is routinely performed for aircrew candidates for the Israeli Air Force. All echocardiographic examinations performed between 1994 and 2010 in which tricuspid regurgitation was present, a prerequisite for echocardiographic PASP measurement, were collected. Subjects with morphologic abnormalities were excluded. PASP was calculated using the simplified Bernoulli equation, with right atrial pressure assumed to be 5 mm Hg. The associations between PASP and clinical and echocardiographic characteristics were studied.Results: Subjects were healthy young adults aged 17 to 29 years. Evidence of tricuspid regurgitation was found in 1,900 of 6,598 subjects. The estimated mean PASP value was 31.2 ± 4.5 mm Hg, and the upper 95th percentile was 34 mm Hg. In univariate analysis, PASP was correlated with left ventricular end-diastolic and end-systolic diameters. A multivariate linear regression model including age; diastolic blood pressure; echocardiographic measurements of aortic root, left atrial, and left ventricular end-diastolic diameters; and left ventricular mass explained only 7% of the variability in PASP.Conclusions: PASP in young, physically fit subjects may be higher than previously reported in the general population and is poorly explained by age, blood pressure, and other echocardiographic parameters.

Exercise Strain Rate Imaging Demonstrates Normal Right Ventricular Contractile Reserve and Clarifies Ambiguous Resting Measures in Endurance Athletes - Corrected Proof

2011-12-23

Background: The significance of reduced right ventricular (RV) deformation reported in endurance athletes (EAs) is unclear, highlighting the ambiguities between physiologic RV remodeling and pathology. The aim of this study was to test the hypothesis that RV functional reserve would be normal in EAs despite reduced deformation measures at rest.Methods: Forty EAs and 15 nonathletes (NAs) performed maximal incremental exercise with simultaneous echocardiographic measures of RV function. Two-dimensional (2D) and color-coded Doppler acquisitions were used to quantify peak systolic strain and strain rate (SRs) for the basal, mid, and apical RV free wall. A second surrogate of contractility, the RV end-systolic pressure-area relationship, was calculated from the tricuspid regurgitant velocity and the RV end-systolic area. Changes in multiple measures obtained throughout exercise were used to assess the affect of exercise on RV contractility.Results: Compared with NAs at rest, basal RV strain and SRs were reduced in EAs, with good agreement between 2D and Doppler methods. During exercise, there was a strong linear correlation between heart rate and global SRs (r = −0.74 and r = −0.84 for Doppler and 2D methods, respectively, P < .0001), which was similar for EAs and NAs (P = .21 and P = .97 for differences in mean regression slopes by Doppler and 2D echocardiography, respectively). Exercise-induced increases in the RV end-systolic pressure-area relationship were also similar for EAs and NAs (P = .42). There was a strong correlation between RV global SRs and the RV end-systolic pressure-area relationship during exercise (r = 0.71, P < .0001).Conclusions: Comparable RV contractile reserve for EAs and NAs suggests that the lower resting values of RV in EAs may represent physiologic changes rather than subclinical myocardial damage.

Coronary Flow in Neonates with Impaired Intrauterine Growth - Corrected Proof

Elhadi H. Aburawi, Peter Malcus, Ann Thuring, Vineta Fellman, Erkki Pesonen — 2011-12-19

Background: Subclinical myocardial injury has been reported in newborns with fetal weights < 2 SDs for gestational age. Intrauterine growth restriction might affect cardiac function and coronary flow (CF).Methods: Seventeen newborns with intrauterine growth restriction and 15 age-matched healthy controls were enrolled in the study. Blood flow in the umbilical artery and maternal uterine artery was assessed using Doppler velocimetry. Cardiac function and left anterior descending coronary artery CF were measured using transthoracic Doppler echocardiography at 1 week of age.Results: The mean growth deviation of the newborns from normal was −2.5 ± 0.2 SDs. Percentage left ventricular shortening fraction was 39 ± 4.3% in patients and 42 ± 4.1% in controls (P = .40), and the mean left ventricular mass index was 86.6 g/m2 in patients and 73.7 g/m2 in controls (P < .01). The mean left anterior descending coronary artery diameter was 0.99 ± 0.1 mm in patients and 0.8 ± 0.1 mm in controls (P = .002). The left anterior descending coronary artery flow velocity-time integral was correlated with left ventricular mass index (r = 0.31, P = .007) and with mitral peak E/A ratio (r = 0.74, P = .01). Intrauterine growth restriction was associated with increased peak flow velocity in diastole (34.5 ± 4 vs 19 ± 6 cm/sec in controls, P = .0001), as well as increased CF (37 ± 7.3 vs 8.2 ± 3.0 mL/min in controls, P = .001).Conclusions: CF is significantly increased in neonates with impaired intrauterine growth. Left ventricular mass index is increased, but systolic and diastolic function remains normal. The clinical significance of increased CF is unclear, but it might lead to decreased CF reserve.

Longitudinal Left Ventricular Function in Normotensive Prediabetics: A Tissue Doppler and Strain/Strain Rate Echocardiography Study - Corrected Proof

Köksal Ceyhan, Hasan Kadi, Fatih Koç, Ataç Çelik, Ahmet Öztürk, Orhan Önalan — 2011-12-16

Background: Although diabetes mellitus is well known to result in systolic and diastolic left ventricular (LV) dysfunction at the subclinical level, even when it is not accompanied by hypertension and coronary artery disease, this situation has not been sufficiently investigated in prediabetes, which is the precursor of diabetes. The aims of the present study were to investigate LV systolic and diastolic function in normotensive and low-risk prediabetic and diabetic subjects for coronary disease using sensitive tissue Doppler echocardiographic parameters, to investigate early possible negative effects of glucose metabolism impairment on LV longitudinal function.Methods: Two hundred subjects (92 with prediabetes, 48 with type 2 diabetes, and 60 age-matched healthy volunteers) were studied by conventional, tissue Doppler, and strain and strain rate echocardiography. All study subjects were normotensive, and coronary artery disease was excluded. Forty-eight patients had isolated fasting glucose impairment, and 44 patients had combined fasting glucose and glucose tolerance impairment. Longitudinal peak systolic strain and the peak systolic and diastolic strain rates of six walls in the apical four-chamber, long-axis, and two-chamber views were evaluated.Results: Clinical and standard echocardiographic characteristics were comparable among all groups. Mean systolic (P = .01) and diastolic (P = .02) tissue velocities, mean strain (P = .004), and mean systolic (P = .002) and diastolic (P = .001) strain rates were significantly lower in the diabetic groups than in control subjects. There were no difference between patients with isolated fasting glucose impairment and controls for tissue Doppler parameters, but mean early diastolic tissue velocity and mean strain and strain rates were statistically lower in patients with combined fasting glucose and glucose tolerance impairment compared with controls (P < .05).Conclusions: LV longitudinal systolic and diastolic function was impaired in both normotensive diabetic and prediabetic patients.

The Right Ventricle of the Endurance Athlete: The Relationship between Morphology and Deformation - Corrected Proof

2011-12-15

Background: The aims of this study were to establish absolute ranges for right ventricular (RV) structural and functional parameters for endurance athletes and to establish any impact of body size. These data may help differentiate physiologic conditioning from arrhythmogenic RV cardiomyopathy.Methods: A prospective observational study design was used, and standard two-dimensional echocardiography was performed on 102 endurance athletes, providing RV structural indices. A two-dimensional strain (ε) technique was used to provide indices of RV ε and strain rate. The association of RV chamber size to body surface area (BSA) and functional indices was examined by simple ratio scaling as well as adoption of the general, nonlinear allometric model.Results: The values for RV inflow, outflow, length, and diastolic area were greater than published “normal ranges” in 57%, 40%, 69%, and 59% of the population, respectively, while 28% of the population had RV outflow tract values greater than the proposed “major criteria” for arrhythmogenic RV cardiomyopathy. Simple ratio scaling for all RV dimensions to BSA did not produce size independence, whereas scaling for BSA allometrically did. Strain and strain rate values were consistent with published normal ranges, and there is no evidence to suggest that scaling is required.Conclusions: RV chamber dimensions are larger in endurance athletes than those described by “normal ranges” and frequently meet the major criteria for the diagnosis of arrhythmogenic RV cardiomyopathy. Functional assessment of RV ε may aid in this differential diagnosis. RV size is allometrically related to BSA and therefore scaling for population-specific b exponents is encouraged.

Accuracy of Matrix-Array Three-Dimensional Echocardiographic Measurements of Aortic Root Dilation and Comparison with Two-Dimensional Echocardiography in Pediatric Patients - Corrected Proof

Cory V. Noel, Raylene M. Choy, Joel R. Lester, Brian D. Soriano — 2011-12-12

Background: Cardiac magnetic resonance imaging has demonstrated that the aortic root may be dilated in a dimension that two-dimensional echocardiography (2DE) is not able to interrogate. In the standard parasternal long-axis view, only a portion of the aortic root in the anteroposterior (AP) dimension can be visualized, as opposed to three-dimensional (3D) echocardiography (3DE), which can capture the entire root in an infinite number of planes. The purposes of the present study were to compare measurements of dilated aortic roots between 3DE and 2DE and to evaluate interobserver variability on 3DE.Methods: Thirty-one patients (median age, 13 years) with aortic root dilation were identified. Two-dimensional echocardiographic images and full-volume electrocardiographically gated 3D echocardiographic (3DE) images were obtained. Two blinded observers measured six dimensions of the aortic root in the short-axis view: three in the AP dimension and three in the transverse dimensions. Two-dimensional echocardiographic measurements were made by a third blinded observer. The largest AP 3DE measurement was compared with two-dimensional echocardiographic measurements. Interobserver 3DE measurements were also compared.Results: The median aortic root Z score was +2.63. Maximum 3DE measurement in any plane of the root size was significantly greater than on 2DE (P < .0001). The largest AP dimension by 3DE was significantly greater than on 2DE (P = .001). There was no significant interobserver variability for the largest dimension or those in the AP dimension, but a difference was found in the transverse dimension (P = .02).Conclusions: Three-dimensional echocardiography compares favorably with 2DE in the evaluation of aortic root dilation in patients with known histories of aortic root disease. Three-dimensional echocardiography found that the largest diameter measured was significantly larger than on 2DE. The interobserver variability of 3DE is low, particularly in the AP dimension and in identifying the largest diameter. Three-dimensional echocardiography can be a useful technique in the periodic surveillance of patients with aortic root dilation.

Head-to-Head Comparison of Peak Supine Bicycle Exercise Echocardiography and Treadmill Exercise Echocardiography at Peak and at Post-Exercise for the Detection of Coronary Artery Disease - Corrected Proof

2011-12-05

Background: Supine bicycle exercise (SBE) echocardiography and treadmill exercise (TME) echocardiography have been used for evaluation of coronary artery disease (CAD). Although peak imaging acquisition has been considered unfeasible with TME, higher sensitivity for the detection of CAD has been recently found with this method compared with post-TME echocardiography. However, peak TME echocardiography has not been previously compared with the more standardized peak SBE echocardiography. The aim of this study was to compare peak TME echocardiography, peak SBE echocardiography, and post-TME echocardiography for the detection of CAD.Methods: A series of 116 patients (mean age, 61 ± 10 years) referred for evaluation of CAD underwent SBE (starting at 25 W, with 25-W increments every 2–3 min) and TME with peak and postexercise imaging acquisition, in a random sequence. Digitized images at baseline, at peak TME, after TME, and at peak SBE were interpreted in a random and blinded fashion. All patients underwent coronary angiography.Results: Maximal heart rate was higher during TME, whereas systolic blood pressure was higher during SBE, resulting in similar rate-pressure products. On quantitative angiography, 75 patients had coronary stenosis (≥50%). In these patients, wall motion score indexes at maximal exercise were higher at peak TME (median, 1.45; interquartile range [IQR], 1.13–1.75) than at peak SBE (median, 1.25; IQR, 1.0–1.56) or after TME (median, 1.13; IQR, 1.0–1.38) (P = .002 between peak TME and peak SBE imaging, P < .001 between post-TME imaging and the other modalities). The extent of myocardial ischemia (number of ischemic segments) was also higher during peak TME (median, 5; IQR, 2–12) compared with peak SBE (median, 3; IQR, 0–8) or after TME (median, 2; IQR, 0–4) (P < .001 between peak TME and peak SBE imaging, P < .001 between post-TME imaging and the other modalities). ST-segment changes in patients with CAD and normal baseline ST segments were higher during TME (median, 1 mm [IQR, 0–1.9 mm] vs 0 mm [IQR, 0–1.5 mm]; P = .006). The sensitivity of peak TME, peak SBE, and post-TME echocardiography for CAD was 84%, 75%, and 60% (P = .001 between post-TME and peak TME echocardiography, P = .055 between post-TME and peak SBE echocardiography), with specificity of 63%, 80%, and 78%, respectively (P = NS) and accuracy of 77%, 77%, and 66%, respectively (P = NS). Peak TME echocardiography diagnosed multivessel disease in 27 of the 40 patients with stenoses in more than one coronary artery, in contrast to 17 patients with peak SBE imaging and 12 with post-TME imaging (P < .05 between peak TME imaging and the other modalities). Image quality was similar with the three techniques. The duration of the test was longer with SBE echocardiography (9.5 ± 3.8 vs 7.6 ± 2.5 min, P < .001).Conclusions: During TME and SBE, patients achieve similar double products. Ischemia is more extensive and frequent with peak TME, which makes peak TME a more valuable exercise echocardiographic modality to increase sensitivity. However, peak SBE should be preferred to TME if the latter is performed with postexercise imaging acquisition.

Right-Heart Function Related to the Results of Acute Pulmonary Vasodilator Testing in Patients with Pulmonary Arterial Hypertension Caused by Connective Tissue Disease - Corrected Proof

2011-12-05

Background: Acute pulmonary vasodilator testing is important for patients with pulmonary arterial hypertension, but little is known about the predictors of response to such testing.Methods: Forty-eight patients (mean age, 41.3 ± 11.6 years; 91.7% women) with pulmonary arterial hypertension associated with connective tissue diseases who underwent right-heart catheterization and acute pulmonary vasodilator testing were prospectively recruited. Echocardiography was performed before and immediately after testing.Results: There were 14 responders (29.2%) to acute pulmonary vasodilator testing. Responders had lower pulmonary vascular resistance, higher peak systolic velocity of the lateral tricuspid valve annulus (right ventricular [RV] S′) and tricuspid annular plane systolic excursion, and smaller RV end-diastolic area. After vasodilator testing, mean pulmonary artery pressure and pulmonary vascular resistance decreased significantly in both groups, cardiac index increased significantly in responders, and RV function improved significantly in nonresponders. Receiver operating characteristic curve analysis identified an optimal cutoff value for RV S′ of ≥10.5 cm/sec to predict response, with sensitivity of 71% and specificity of 71%. There were more responders among patients with RV S′ ≥ 10.5 cm/sec (45.5% vs 15.4%, P = .02). On multivariate logistic regression analysis, RV S′ ≥ 10.5cm/sec emerged as an independent predictor of response (odds ratio, 4.58; 95% confidence interval, 1.18–17.79; P = .02).Conclusions: Right-heart function is better in responders to acute pulmonary vasodilator testing than in nonresponders among patients with pulmonary arterial hypertension associated with connective tissue diseases, and pulmonary vasodilators may improve RV function in nonresponders and cardiac index in responders. RV S′ is a simple and clinically useful tool for predicting the results of pulmonary vasodilator testing.

Strain, Strain Rate and the Force Frequency Relationship in Patients with and without Heart Failure - Corrected Proof

Susanna Mak, Harriette G.C. Van Spall, Rodrigo V. Wainstein, Zion Sasson — 2011-12-05

Background: The aim of this study was to examine the effect of heart rate (HR) on indices of deformation in adults with and without heart failure (HF) who underwent simultaneous high-fidelity catheterization of the left ventricle to describe the force-frequency relationship.Methods: Right atrial pacing to control HR and high-fidelity recordings of left ventricular (LV) pressure were used to inscribe the force-frequency relationship. Simultaneous two-dimensional echocardiographic imaging was acquired for speckle-tracking analysis.Results: Thirteen patients with normal LV function and 12 with systolic HF (LV ejection fraction, 31 ± 13%) were studied. Patients with HF had depressed isovolumic contractility and impaired longitudinal strain and strain rate. HR-dependent increases in LV+dP/dtmax, the force-frequency relationship, was demonstrated in both groups (normal LV function, baseline to 100 beats/min: 1,335 ± 296 to 1,564 ± 320 mm Hg/sec, P < .0001; HF, baseline to 100 beats/min: 970 ± 207 to 1,083 ± 233 mm Hg/sec, P < .01). Longitudinal strain decreased significantly (normal LV function, baseline to 100 beats/min: 18.0 ± 3.5% to 10.8 ± 6.0%, P < .001; HF: 9.4 ± 4.1% to 7.5 ± 3.4%, P < .01). The decrease in longitudinal strain was related to a decrease in LV end-diastolic dimensions. Strain rate did not change with right atrial pacing.Conclusions: Despite the inotropic effect of increasing HR, longitudinal strain decreases in parallel with stroke volume as load-dependent indices of ejection. Strain rate did not reflect the modest HR-related changes in contractility; on the other hand, the use of strain rate for quantitative stress imaging is also less likely to be confounded by chronotropic responses.

Altered Left Ventricular Tissue Velocities, Deformation and Twist in Children and Young Adults with Acute Myocarditis and Normal Ejection Fraction - Corrected Proof

2011-11-21

Background: Acute myocarditis is a significant cause of sudden death in young adults, and accurate screening for subclinical disease is needed. The aim of this study was to test the hypothesis that newer measures of tissue deformation and twist can detect ventricular dysfunction in patients with myocarditis and preserved left ventricular ejection fractions (LVEFs).Methods: Twenty-eight consecutive patients (median age, 26.5 years; interquartile range, 19.3–33.8 years) with normal LVEFs and cardiovascular magnetic resonance features of myocarditis were prospectively recruited. Left ventricular tissue velocities, deformation, and twist were measured and compared with values in 64 healthy controls (median age, 25.1 years; interquartile range, 13.5–31.7 years).Results: Patients with myocarditis had reduced annular e′ velocity and longitudinal and circumferential strain parameters (P < .01) but similar LVEFs. Reduced lateral e′ velocity (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.34–2.34), longitudinal strain (OR, 1.81; 95% CI, 1.38–2.38), circumferential early diastolic strain rate (OR, 1.31; 95% CI, 1.08–1.71), increased twist rate (OR, 1.02; 95% CI, 1.01–1.04), and earlier time to peak twist (OR, 0.80; 95% CI, 0.72–0.88) were identified as independent predictors of myocarditis, with abnormalities in any two of five predictors having 93% sensitivity and 91% specificity. Longitudinal strain parameters and lateral e′ velocity were improved at 1 year (P ≤ .03) but remained reduced compared with controls (P ≤ .02).Conclusions: Patients with acute myocarditis and normal LVEFs had detectable left ventricular systolic and diastolic dysfunction on echocardiography. Tissue velocity, deformation, and twist parameters have the potential to improve the detection of patients with myocarditis and preserved LVEFs.