Abdominal aortic aneurysm screening during transthoracic echocardiography:Cardiologist and vascular medicine specialist interpretation

AIM: To study the interobserver variability between a cardiologist and vascular medicine specialist in the screening of the abdominal aorta during transthoracic echocardiography (TTE). METHODS: Consecutive patients, > 55 years of age, underwent abdominal aortic imaging following standard TTE. Two cardiologists and one vascular medicine specialist performed a blinded review of the images. Interobserver agreement of abdominal aortic size was determined by the correlation coefficient and paired t test. Interobserver reliability for each cardiologist was assessed using Bland-Altman plots. RESULTS: Ninety patients were studied. The mean age of patients was 72 ± 10 years and 48% were male. The mean aortic diameter was 2.31 ± 0.50 cm and 5 patients (5.5%) had an abdominal aortic aneurysm (AAA). The additional time required for the ab-dominal aortic images was 4.4 ± 0.9 min per patient. Interobserver agreement between the 2 cardiologist interpreters and the vascular medicine specialist was excellent (P > 0.05 for all comparisons). On Bland-Altman analysis ofinterobserver reliability, the 95% lower and upper limits for measurement by the cardiologists were 84% and 124% of that of the vascular specialist. CONCLUSION: The assessment of the abdominal aorta during a routine TTE performed by a cardiologist is accurate in comparison to that of a vascular medicine specialist. In selected patients undergoing TTE, the detection rate of AAA is significant. Additional time and effort required to perform imaging of the abdominal aorta after TTE is less than 5 min.

Congenital Heart Diseases Diagnosed on Transthoracic Echocardiography: Perspectives from the University of Maiduguri Teaching Hospital, Nigeria

In a retrospective study of 1224 transthoracic echocardiograms performed between January 2011 and December 2013, we evaluated the spectrum of congenital heart disease (CHD) diagnosed at a tertiary referral centre in Maiduguri, north-eastern Nigeria. Diagnosis of CHD was made in 88 (8.3%) subjects, comprising 23 (26.1%) adults and 65 (73.9%) aged less than 18 years. Forty six (52.3%) of those with CHD were females, while 42 (47.7%) were males. The frequencies of the CHD in decreasing order were: ventricular septal defect 23 (26.1%), tetralogy of Fallot (TOF) 14 (15.9%) and atrial septal defect (ASD) and atrioventricular septal defect (AVSD) were 11 (12.5%) each. One of the patients with AVSD had Ellis Van Creveldt syndrome. Six (6.8%) cases of patent ductus arteriosus (PDA) were diagnosed in those younger than 18 years, while all the 5 (5.7%) cases of Ebstein’s anomaly were diagnosed in adults. There were 6 (6.8%) cases of Eisenmenger syndrome involving three cases of AVSD, one case of ASD and two cases of Ebstein’s anomaly. Timely definitive cares for these patients are still lacking in Nigeria and many areas of sub-Saharan Africa. We recommend sensitization of all relevant clinicians to actively look for congenital heart defects. Pulse oximetry and postnatal echocardiographic new-born screening which were previously validated should be implemented at secondary and tertiary levels, and efforts should be made towards providing the needed care for patients with CHD.

Computed tomography versus transthoracic echocardiography in the detection of complex congenial heart diseases in china:a meta-analysis

Objective:To perform a meta-analysis to evaluate the diagnostic performance of computed tomography(CT) and transthoracic echocardiography(TTE) in complex congenital heart diseases(CHD) in China.Methods:MEDLINE,Cochrane library and China National Knowledge Infrastructure(CNKI) database from January 1966 to October 2010,were searched for initial studies in China.All the studies,published in English or Chinese,used TTE,CT,or both as diagnostic tests for CHD and reported the rate of true-positive,true-negative,false-positive and false-negative diagnoses of CHD from TTE and CT findings with the surgical results as the 'gold-standard'(15 studies,XX patients) were collected.The statistic software package,'Meta-Disc 1.4',was used to conduct data analysis.A covariate analysis was used to evaluate the influence of patient or study-related factors on sensitivity.Results:Pooled sensitivity for diagnosis of CHD were 95% [95% confidence interval(CI):94%~96%] for CT studies and 87%(95% CI:85%~88%) for TTE studies.The difference between the pooled sensitivity of CT and that of TTE was statistically significant(P<0.001).TTE had higher sensitivity [0.96(95% CI:0.94~0.97)] for cardiac malformation but lower sensitivity [0.78(95% CI:0.76~0.81)] for extracardiac malformation than CT.Conclusion:CT can provide added diagnostic information compared with TTE in patients with CHD in China,especially for patients suspected of extracardiac malformation.

Study on linage Acquisition of Transthoracic Echocardiography in Mechanically Ventilated ICU Patients

Objective This study aimed to determine which parameters in transthoracic echocardiography(TTE)are more likely to be affected when applied in a critical care setting with mechanical ventilation.Methods Ninety mechanically ventilated ICU patients were enrolled into the study group.The control group consisted of 90 patients who underwent interventional therapy.All patients had bedside TTE for parametric measurements including the right ventricular size,septal kinetics and left ventricular ejection fraction(LVEF)by eyeballing(visual assessment),the tricuspid annular plane systolic excursion(TAPSE),mitral annular plane systolic excursion(MAPSE)by M-mode sonography,the right ventricular outflow tract velocity-time integral(RVOT VTI)and left ventricular outflow tract velocity-time integral(LVOT VTI)by pulse-Doppler,the right ventricular fraction of area change(FAC)and left ventricular ejection fraction(LVEF Simpson)by endocardium tracing.We compared the differences in the frequency of optimal image acquisition in assessments of these parameters between the two groups,as well as the differences in acquisition rates of parameter measurements in ventilated ICU patients.Results There were significantly fewer patients in the study group than in the control group who had optimal images acquisitions for parameter assessments with M-mode method,pulse Doppler method and endocardiumtracing method(P<0.05);no significant difference was obsered in the number of patients with optimal images for RV eyeballing and LVEF eyeballing between the two groups.In the study group,significantly fewer optimal images were acquired for FAC than forTAPSE(22.2%vs、72.2%,χ2=45.139,P<0.001)and RVOT VTI(22.2%vs.71.1%,χ2=43.214,P<0.001);there were also fewer optimal images acquired for LVEF Simpson than for MAPSE(37.8%ys.84.4%,χ2=41.236,P<0.001)and LVOT VTI(37.8%vs.85.6%,/=43.455,P<0.001).Conclusions Images acquisition of optimal TTE images tend to be difRcult in mechanically ventilated ICU patients,but eyeballing method for functional evaluation could be an alternative method.For quantitative parameters measurements,M-mode based longitudinal function evaluation and pulse Doppler-based VTI were superior to the endocardium-tracing based parameter assessments.

Focus assessed transthoracic echocardiography (FATE) to diagnose pleural effusions causing haemodynamic compromise

The clinical assessment of patients with respiratory and circulatory problems can be complex, time consuming and have a high incidence of error. Bedside transthoracic ultrasound (US) is a useful adjunctive test in the evaluation of acutely unstable patients. This case series describes the use of the Focus Assessed Transthoracic Echocardiography (FATE) protocol to diagnose unsuspected pleural collections of fluid and how drainage significantly contributes to the haemodynamic improvement seen in these patients.

Transthoracic echocardiography assists appropriate pulmonary artery catheter placement: An observational study

AIM: To investigate the utility of transthoracic echocardiography in confirming appropriate pulmonary artery catheter(PAC) placement. METHODS: Three commonly used transthoracic echocardiography(TTE) views were used to confirm PAC position in 103 patients undergoing elective cardiac surgery- the parasternal short axis right ventricular inflow-outflow view; the subcostal short axis right ventricular inflow-outflow view; and the parasternal short axis ascending aortic view. All PACs were inserted by the managing anesthesiologist under pressure waveform guidance alone, who was blinded to all sonographic information. A sonographer blinded to all pressure waveform information confirmed visualisation of an "empty" PA before PAC insertion, and visualisation of the PAC balloon in the main PA(MPA) or right PA(RPA) after attempts at placement were complete. Agreement, sensitivity and specificity of TTE in confirming appropriate PAC placement was compared against pressure waveformguidance as the "gold standard". The successful view used was compared against patients' anthropomorphic indices, presence of lung hyperinflation, and insertion of PAC during positive pressure ventilation. Agreement between TTE and pressure waveform guidance was analysed using Cohen's Kappa statistic. The relative proportion of total RPA seen by subcostal vs parasternal TTE views was also compared with a further 20 patients' computed tomography(CT) pulmonary angiograms(CTPA), to determine efficacy in detection of distal RPA PAC placement. RESULTS: Appropriate positioning of the PAC balloon, and its to-and-fro movement consistent with a nonwedged state, within the MPA or RPA was confirmed by TTE in 98 of the 103 patients [sensitivity 95%(95%CI: 89%-98%)], and absence of the PAC balloon before insertion correctly established in 100 patients [specificity 97%(92%-99%)]. This was in very good agreement with pressure waveform guidance [Cohen's Kappa 0.92,(0.87-0.98)]. The subcostal view was the best view to visualise the PAC tip when it was placed in the right pulmonary artery(OR 70, P < 0.0001), was more successful in patients with COAD(OR 9.5, P = 0.001), and visualized 61%(vs 44% by parasternal views, P < 0.001) of mean RPA lengths compared with CTPA; however the parasternal views were more successful in patients with higher body mass indexs(OR 0.78 for success with subcostal views, P < 0.001). There was a trend towards insertion during intermittent positive pressure ventilation favoring visualisation by subcostal views(OR 3.9, P = 0.08). The subcostal view visualized a greater length of the RPA than parasternal views(3.9 cm vs 2.9 cm, P < 0.0001). PACs were more often placed in the MPA than RPA(80 vs 18 patients). Three patient's pulmonary arteries were not visible by any TTE view; in a further 2 patients, despite preinsertion visualisation of their pulmonary arteries, the PAC balloon was not visible by any view with TTE where correct placement by pressure waveform was unequivocal.

Assessment of Coronary Flow Velocity Reserve by Noninvasive Transthoracic Doppler Echocardiography in Patients with Angiographically Normal Coronary Arteries

Summary： The measurement of coronary flow velocity reserve （CFVR） by transthoracic Doppler echocardiography （TTDE） with invasive intracoronary Doppler flow wire technique （ICD） was validated and the pathological factors which influence CFVR in patients with angiographically normal coronary arteries were analyzed. CFVR was determined successfully in left anterior descending artery （LAD） in 37 of 40 patients with angiographically normal coronary arteries （men 22, women 15, age 20-75 years, mean age 54±12 years）. Coronary flow velocity was measured in the distal LAD by TTDE with contrast enhancement at baseline and during intravenous adenosine infusion of 110 μg/ kg per min within 48 h after ICD technique. Average peak velocity at baseline （APVb）, average peak velocity during hyperemia （APVh） and CFVR determined from TTDE were correlated closely with those from ICD measurements （APVb： y= 0. 64x＋ 5. 04, r=0. 86, P〈0. 001; APVh： y=0. 63x＋14. 36, r=0.82, P〈0.001; CFVR： y=0.65xq-0.92, r=0.88, P〈0.001）. For CFVR measurements, the mean differences between TTDE and ICD methods were 0. 12±0.39. CFVR in patients with history of hypertension was significantly lower than that in patients without history of hypertension （P〈0.05）. Intravascular ultrasound （IVUS） was performed in 34 patients. Plaque formation was found in LAD by IVUS in 17 （50%） patients. No significant difference in CFVR was found between the patients without plaque formation （3. 11±0. 49） and those with plaque formation （2. 76±0.53, P=0. 056）. It is suggested that TTDE with contrast enhancement provides reliable measurement of APV and CFVR in the distal I.AD. The early stage of atherosclerosis could be detected by IVUS, which may be normal in angiography. CFVR is impaired in patients with history of hypertension compared with that in patients without history of hypertension.

Value of Acceleration Flow in the Left Anterior Descending Coronary Artery for the Detection of Coronary Artery Stenosis by Transthoracic Coronary Color Doppler Echocardiography

Summary： Whether the localized flow acceleration occurs in the resting stenotie left anterior descending coronary artery was explored and its value for detection of coronary stenosis estimated. Blood flow in the left anterior descending coronary arteries in 45 patients was detected by transthoratio color Doppler echocardiograph and multipoint pulse Doppler spectrums were recorded in the same segment. The ratio of the maximal peak diastolic velocity to the minimal peak diastolic velocity was calculated. The ratio ≥1.5 was the cutoff value for the presence of localized acceleration flow. There were 23 patients with localized acceleration flow examined by eehoeardiography. Twenty of them were found to have luminal diameter stenosis （60%-98%） in the left anterior descending coronary arteries by coronary angiography and 3 patients were normal. There were 22 patients without localized acceleration flow examined by eehoeardiography. Eighteen of them had no or %60 stenosis. Four patients had serious stenosis （≥95%） or occluded segments in the left anterior descending coronary arteries on coronary angiography. The ratio of the maximal peak diastolic velocity to the minimal peak diastolic velocity was significantly higher in patients with left anterior descending coronary artery stenosis than that in those without stenosis （1.9±0.3 vs 1.3±0.2, P〈0.01） and it correlated significantly with left anterior descending coronary artery stenosis （r=0.77, P〈0.01）. The specificity by using the ratio≥1. 5 for stenosis detection was 85.7% （18/ 21）, and the sensitivity was 83.3% （20/24）. This study demonstrated that local blood flow velocity was increased in the resting stenotie left anterior descending coronary artery. Transthoraeie color Doppler eehoeardiography is a reliable noninvasive method to detect localized acceleration flow in the left anterior descending coronary artery stenosis and it is useful in the noninvasive diagnosis of stenosis in the left anterior descending coronary artery.

Non-invasive Assessment of Coronary Flow Velocity Reserve: A New Method Using Transthoracic Doppler Echocardiography

Summary: Transthoracic Doppler echocardiography (TTDE) allows noninvasive flow measurement in the distal left anterior descending artery (LAD). The feasibility of detecting coronary flow by contrast-enhanced TTDE with second harmonic technique was assessed, the coronary flow velocity reserve (CFVR) was evaluated in comparison to intracoronary Doppler flow (ICD) analysis and the CFVR after PTCA in LAD was investigated. In 77 (96 %) of 80 patients, CFVR was successfully determined with intravenous adenosine infusion. Doppler signal quality was evaluated in the first 46 patients by use of intravenous Levovist infusion and second harmonic technique. The Doppler flow was not visible in 1 patient only. CFVR determined from TTDE (2.77±0.65) was correlated closely with those from ICD (2.88±0.78) measurements (y=0.73x+0.67, r=0.87, P<0.001). In conclusion, TTDE is a feasible method and provides reliable data on CFVR which can be used for follow-up after PTCA.

Effects of sevoflurane on left ventricular function by speckletracking echocardiography in coronary bypass patients: A randomized trial

The present study aimed to dynamically observe the segmental and global myocardial movements of the left ventricle during coronary artery bypass grafting by transesophageal speckle-tracking echocardiography,and to assess the effect of sevoflurane on cardiac function.Sixty-four patients scheduled for the off-pump coronary artery bypass grafting were randomly divided into a sevoflurane-based anesthesia(AS)group and a propofolbased total intravenous anesthesia(AA)group.The AS group demonstrated a higher absolute value of left ventricular global longitudinal strain than that of the AA group at both T1(after harvesting all grafts and before coronary anastomosis)and T_(2)(30 min after completing all coronary anastomoses)(P<0.05).Moreover,strain improvement in the segment with the highest preoperative strain was significantly reduced in the AS group,compared with the AA group at both T1 and T_(2)(P<0.01).The flow of the left internal mammary artery-left anterior descending artery graft was superior,and the postoperative concentration of troponin T decreased rapidly in the AS group,compared with the AA group(P<0.05).Compared with total intravenous anesthesia,sevoflurane resulted in a significantly higher global longitudinal strain,stroke volume,and cardiac output.Sevoflurane also led to an amelioration in the condition of the arterial graft.Furthermore,sevoflurane significantly reduced strain improvement in the segmental myocardium with a high preoperative strain value.The findings need to be replicated in larger studies.

Intelligent diagnosis of atrial septal defect in children using echocardiography with deep learning

Background Atrial septal defect(ASD)is one of the most common congenital heart diseases.The diagnosis of ASD via transthoracic echocardiography is subjective and time-consuming.Methods The objective of this study was to evaluate the feasibility and accuracy of automatic detection of ASD in children based on color Doppler echocardiographic static images using end-to-end convolutional neural networks.The proposed depthwise separable convolution model identifies ASDs with static color Doppler images in a standard view.Among the standard views,we selected two echocardiographic views,i.e.,the subcostal sagittal view of the atrium septum and the low parasternal four-chamber view.The developed ASD detection system was validated using a training set consisting of 396 echocardiographic images corresponding to 198 cases.Additionally,an independent test dataset of 112 images corresponding to 56 cases was used,including 101 cases with ASDs and 153 cases with normal hearts.Results The average area under the receiver operating characteristic curve,recall,precision,specificity,F1-score,and accuracy of the proposed ASD detection model were 91.99,80.00,82.22,87.50,79.57,and 83.04,respectively.Conclusions The proposed model can accurately and automatically identify ASD,providing a strong foundation for the intelligent diagnosis of congenital heart diseases.

Utilization of Transthoracic Echocardiography Is Associated with a Decreased 6-month Readmission Rate in Hospitalized Heart Failure:A Propensity Score-matched Analysis

Objective::Repeated hospitalization due to congestion is a characteristic of the whole course of heart failure.Echocardiography can be used to assess cardiac function and volume status.However,whether echocardiography can reduce the rehospitalization rate remains unclear.This study aimed to evaluate the impact of transthoracic echocardiography(TTE)use on readmission rates in hospitalized patients with heart failure.Methods::The study was based on the Zigong heart failure database,which contained information on 2,008 adult patients with heart failure admitted to the Zigong Fourth People’s Hospital(Sichuan Province,China)from December 2016 to June 2019.Patients were divided into 2 groups according to the usage of TTE on the day of hospital admission(TTE group(1,371 patients)and no TTE group(637 patients),respectively).The primary outcome was the 6-month readmission rate.The statistical approaches used included multivariate Cox regression,propensity score analysis,and an inverse probability weighting model to ensure the robustness of the findings.Results::A significant reduction in 6-month readmission rate was observed among the TTE group compared with the no TTE group(hazard ratio=0.60,95%confidence interval(CI)=0.52-0.69,P<0.001).The frequencies of intravenous nitrates,diuretics,and inotropes during hospitalization were significantly higher in the TTE group compared with those in the no TTE group(10.9%vs.8.3%,88.5%vs.86.2%,and 66.9%vs.65.6%,respectively,all P<0.001).The proportion of patients returning to the emergency department within 6 months was significantly lower in the TTE group compared with the no TTE group(35.6%vs.50.3%,P<0.001).Conclusions::Utilization of TEE on admission day was associated with a reduced 6-month readmission rate in hospitalized patients with heart failure.

Self-Appraisal of Clinical Competence in Echocardiography of Chinese Intensivists Post Basic Echocardiography Training

Objectives To learn the echocardiography skills of intensivists after receiving a basic critical care echocardiography training course,and investigate factors that may influence their performance.Methods We completed a web-based questionnaire that assessed the skills in ultrasound scanning techniques of intensivists who took a training course on basic critical care echocardiography held in 2019 and 2020.MannWhitney test was used to analyze the factors which might affect their performance on image acquisition,recognizing clinical syndrome,and measuring the diameter of inferior vena cava,left ventricular ejection fraction and left ventricular outflow tract velocity-time integral.Results We enrolled 554 physicians from 412 intensive care units across China.Among them,185(33.4%)reported that they had 10%-30%chance of being misled by critical care echocardiography when making therapeutic decision,and 34(6.1%)reported that the chance was greater than 30%.Intensivists who performed echocardiography under the guidance of a mentor and finished ultrasound scanning more than 10 times per week reported significant higher scores in image acquisition,clinical syndrome recognition,and quantitative measurement of inferior vena cava diameter,left ventricular ejection fraction and left ventricular outflow tract velocity-time integral than those without mentor and performing echocardiography 10 times or less per week respectively(all P 0.05).Conclusion The skills in diagnostic medical echocardiography of Chinese intensivists after a basic echocardiographic training course remain low,and further quality assurance training program is clearly warranted.

Real-Time Remote-Mentored Echocardiography in Management of Newborns with Critical Congenital Heart Defects

Background:The management of suspected critical congenital heart defects(CCHD)relies on timely echocardiographic diagnosis.The availability of experienced echocardiographers is limited or even non-existent in many hospitals with obstetric units.This study evaluates remote-mentored echocardiography performed by physicians without experience in imaging of congenital heart defects(CHD).Methods:The setup included a pediatric cardiologist in a separate room,guiding a physician without experience in echocardiographic imaging of CHD in the examination of a symptomatic newborn.This remote-mentoring pair was blinded to the diagnosis of the newborn and presented with a simplified patient history.The echocardiographic images were streamed to the laptop of the mentor,along with a webcam feed showing the probe position.The task was to identify CCHD in need of immediate transfer to a pediatric cardiac surgical center.The result was compared to the previously completed echocardiographic report and the clinical decision of the patient-responsible pediatric cardiologist.Results:During 17 months,15 newborns were recruited.All six newborns with CCHD were correctly labeled by the remotementoring pair.One newborn with Tetralogy of Fallot was erroneously labeled as needing immediate transfer.Eight newborns without CCHD were correctly labeled.Conclusions:Remote-mentored echocardiography performed by examiners without experience in imaging CHD identified all newborns with CCHD in need of immediate transfer for specialist care.The setup shows promising results for improving the management of CCHD in hospitals without continuous pediatric cardiology service.

Current role and future perspectives of artificial intelligence in echocardiography

Echocardiography is an essential tool in diagnostic cardiology and is fundamental to clinical care.Artificial intelligence(AI)can help health care providers serving as a valuable diagnostic tool for physicians in the field of echocardiography specially on the automation of measurements and interpretation of results.In addition,it can help expand the capabilities of research and discover alternative pathways in medical management specially on prognostication.In this review article,we describe the current role and future perspectives of AI in echocardiography.

Analysis of the Diagnostic Value of Echocardiography in Patients with Chronic Heart Failure

Objective:This study aims to analyze the diagnostic value of echocardiography in patients with chronic heart failure.Methods:30 patients with chronic heart failure admitted to our hospital during January 2021 to January 2023 were selected as the observation group,and 30 healthy people who received physical examination in our hospital during the same period were selected as the reference group.Both groups received echocardiography,and the results of the ultrasound examination were compared,and the subjects in the observation group were grouped according to the New York Heart Association(NYHA)cardiac function grading standard.The results of echocardiography in patients with chronic heart failure of different cardiac function grades were compared.Results:The left ventricular ejection fraction(LVEF)and ratio of maximum blood flow in the early diastole(E)to movement speed(A)(E/A)in the observation group were lower than those in the reference group,while the left ventricular posterior wall thickness(LVPWd),left ventricular end-diastolic diameter(LVEDD),left ventricular end-systolic diameter(LVESD),left atrial diameter(LAD),and interventricular septal thickness(IVS)were higher than those of the reference group(P<0.05).With the continuous increase of cardiac function grades,the levels of LVEF and E/A in patients with chronic heart failure continued to decrease,while the levels of LVPWd,LVEDD,LVESD,LAD,and IVS continued to increase,and there were significant differences among the groups(P<0.05).Conclusion:The application of echocardiography in the clinical diagnosis of chronic heart failure can accurately evaluate the changes of cardiac shape and cardiac function,and provide a reliable basis for clinical diagnosis with a high application value.

Research and Application of Transnasal Transesophageal Echocardiography Probe

The intubation of conventional transesophageal echocardiography（TEE） probes into patients causes serious esophagus irritation, and thus the use of TEE probes in pediatric practice is limited. In this study, we aimed at the development of a special probe which could be inserted through the nasopharyngeal cavity into the esophagus to obtain the same high-quality echocardiography images as those obtained by conventional TEE and improve patients＇ experience. During the examination, the patients felt relaxed for a longer time and cooperated with the sonographers in the process of cardiac catheterization conducted in the surgery room or the intensive care unit（ICU）, resulting in improved accuracy of the diagnosis and timely administration of appropriate treatment. Two years ago, Prof. Xin-fang WANG put theories into practice by inserting the probe through the nasal cavity and pharynx into the esophagus of volunteers to successfully detect the heart and great vessels at the retrocardiac space. Later, Prof. Ming-xing XIE performed the transnasal TEE examination in 12 atrial septal defect（ASD） patients and proved the safety and reliability of this method, which could become a new way for clinical diagnosis and treatment.

Value of transthoracic echocardiography combined with cardiac troponin I in risk stratification in acute pulmonary thromboembolism

Background Acute pulmonary thromboembolism （APE） causes right ventricular dysfunction （RVD） and cardiac troponin I （cTnl） elevation. Patients with RVD and cTnl elevation have a worse prognosis. Thus, early detection of RVD and cTnl elevation is beneficial for risk stratification. In this study, we assessed 14-day adverse clinical events and combined RVD on transthoracic echocardiography （TTE） with cTnl in risk stratification among a broad spectrum of APE patients. Methods The prospective multi-centre trial included 90 patients with confirmed APE from 12 collaborating hospitals. Acute RVD on TTE was diagnosed in the presence of at least 2 of the following： right ventricular dilatation （without hypertrophy）, loss of inspiratory collapse of inferior vena cava （IVC）, right ventricular （RV） hypokinesis, tricuspid regurgitant jet velocity 〉2.8 m/s. The study patients were divided into two groups according to clinical and echocardiographic findings at presentation： Group Ⅰ： 50 patients with RVD; Group Ⅱ：40 patients without RVD. Results More than half of the patients （50/90, 55.6%） had RVD. Nearly one third （26/90, 28.9%） of patients had elevated cTnl at presentation and only 4.2% on the fourth day after initial therapy. A multiple Logistic regression model implied RVD, right and left ventricular end-diastolic diameter ratio （RVED/LVED）, and cTnl independently predict an adverse 14-day clinical outcome （P〈0.01）. Receiver operating characteristics （ROC） curves revealed that the cut-off values of RVED/LVED and cTnl yielding the highest discriminating power were 0.65 and 0.11 ng/ml, respectively. Furthermore, the incidence of an adverse 14-day clinical event in patients with RVD and elevated cTnl was greater （40.7%） than in patients with elevated cTnl or positive RVD alone （0% and 8.3%, respectively） （P〈0.001）. Conclusions RVD, RVED/LVED, and cTnl are independent predictors of 14-day clinical outcomes. The patients with RVED/LVED greater than 0.65 and cTnl higher than 0.11 ng/ml at presentation possibly have adverse 14-day events. RVD combined with cTnl can identify a subgroup of APE patients with a much more guarded prognosis.

Reliability of transthoracic echocardiography in estimating the size of Amplatzer septal occluder and guiding percutaneous closure of atrial septal defects

Background In China, transthoracic echocardiography （TTE） is popularly used for pre-intervention examination for atrial septal defect （ASD） and for guiding ASD closure. However, the ability to determine ASD size and the safety and efficacy of l-rE for guiding ASD closure still has not been widely accepted. This study aimed to evaluate the efficacy and safety of l-rE used before, during and after transcatheter ASD closure with Amplatzer septal occluders （ASO）. Methods Sixty-eight subjects （15 men and 53 women; mean age （33.7±17.3） years） were enrolled. TTE was used to measure the diameters and guide transcatheter closure of ASD. The ASD was examined by long-axis view, basal short-axis view, apical four-chamber view and the subcostal view to observe position, diameter and relation with neighbouring structures. The largest diameter was selected as the reference diameter. Patients were divided into 3 groups according to the ASD reference diameter： 22 subjects with ASD diameter 4-14 mm （group A）; 21 subjects with ASD diameter 15-20 mm （group B）; and 25 subjects with ASD diameter 21-33 mm （group C）. Results ASD was occluded successfully in groups A and B. In group C, occlusion failed in 2 cases; 1 case remained with a 3-mm residual shunt sustained until 6-month follow-up. However, at 6-month follow-up, no case of thromboembolism, ASO dislocation or death occurred in the three groups. The diameter of ASD measured by l-rE could accurately predict the ASO size that could successfully occlude the ASD, especially in patients with ASD 〈20 mm. The ASD diameter measured by l-rE correlated well with ASO size （r= 0.925, P〈0.001 ; r=0.976, P〈0.001 ; r=0.929, P〈0.001 respectively）. Conclusions ASD diameter measured by l-rE can accurately estimate the size of the ASO needed for successful closure of ASD. The larger the ASD, the much larger the ASO needed. l-rE is a satisfactory guiding imaging tool for ASD closure.

Massive Pulmonary Embolism in Recovery Period of General Anesthesia： Rapid Diagnosis and Successful Rescue by the Guidance of Transthoracic Echocardiography

Massive pulmonary embolism （PE）, an uncommon event in the perioperative period, is a major challenge to anesthesia management. Massive PE is often associated with an unexpected hemodynamic collapse and severe desaturation without other characteristic changes. It is difficult to make a rapid diagnosis during the perioperative period, especially under general anesthesia. We present a rare case of massive PE diagnosed with transthoracic echocardiography （TTE） in the recovery period of general anesthesia.