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Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.

Background Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (RCHOP) chemotherapy in non‐Hodgkin's lymphoma (NHL) has risk of cardiotoxicity. Purpose To determine the role of myocardial work and biomarkers in subclinical diagnosis and prediction of cardiotoxicity. Methods The 130 NHL patients (52 ± 9 years, 62% men) scheduled for RCHOP, with LVEF>50%, were evaluated at baseline, after third cycle and chemotherapy completion for 3D LVEF, 2D myocardial deformation (longitudinal, radial, circumferential strain ‐ LS, RS, CS) and myocardial work (global constructive work, waste work, work index and work efficiency ‐ GCW, GWW, GWI, GWE). NT‐pro‐BNP and troponin I were determined. Results After chemotherapy ended, 37 patients (28%) (group I) developed asymptomatic cardiotoxicity (8 mild form, 25 moderate form, 4 severe form); 93 patients (group II) did not. After third cycle, all patients had decreased LS, CS, RS, GCW, GWI, GWE and increased GWW, persistent after chemotherapy completion, with significant changes in group I. After third cycle, GWE and GCW were the best independent predictors for LVEF reduction; GWE decrease with>5% after third cycle predicted cardiotoxicity after chemotherapy completed (91% sensitivity, 94% specificity). Conclusions In NHL, myocardial work can diagnose subclinical cardiotoxicity and predict LVEF decline. These parameters should be used for sensitive evaluation of myocardial function during chemotherapy.

Left ventricular volumes (LVVs) and ejection fraction (LVEF) are key elements in the evaluation and follow-up of patients with heart failure with reduced ejection fraction (HFrEF). Therefore, a feasible and reproducible imaging method to be used by both experienced and in-training echocardiographers is mandatory. Our aim was to establish if, in a large echo lab, echocardiographers in-training provide feasible and more reproducible results for the evaluation of patients with HFrEF when using 3-dimensional echocardiography (3-DE) versus 2-dimensional echocardiography (2-DE). Sixty patients with HFrEF (46 males, age: 58 § 17 y) underwent standard transthoracic 2-D acquisitions and 3-D multibeat full volumes of the left ventricle. One expert user in echocardiography (expert) and three echocardiographers with different levels of training in 2-DE (beginner, medium and advanced) measured the 2-D LVVs and LVEFs on the same consecutive images of patients with HFrEF. Afterward, the expert performed a 1-mo training in 3-DE analysis of the users, and both the expert and trainees measured the 3-D LVVs and LVEF of the same patients. Measurements provided by the expert and all trainees in echo were compared. Six patients were excluded from the study because of poor image quality. The mean enddiastolic LVV of the remaining 54 patients was 214 § 75 mL with 2-DE and 233 § 77 mL with 3-DE. Mean LVEF was 35 § 10% with 2-DE and 33 § 10% with 3-DE. Our analysis revealed that, compared with the expert user, the trainees had acceptable reproducibility for the 2-DE measurements, according to their level of expertise in 2-DE (intra-class coefficients [ICCs] ranging from 0.75 to 0.94). However, after the short training in 3-DE, they provided feasible and more reproducible measurements of the 3-D LVVs and LVEF (ICCs ranging from 0.89À0.97) than they had with 2-DE. 3-DE is a feasible, rapidly learned and more reproducible method for the assessment of LVVs and LVEF than 2-DE, regardless of the basic level of expertise in 2-DE of the trainees in echocardiography. In echo labs with a wide range of staff experience, 3-DE might be a more accurate method for the follow-up of patients with HFrEF.

ObjectivesWe sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.MethodsWe measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.ResultsLV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel’s C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ2 = 98.3 vs. χ2 = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ2 = 15.9, p < 0.001 vs. χ2 = 10.8, p = 0.001; 3DE LVESV: χ2 = 24.4, p < 0.001 vs. χ2 = 17.4, p = 0.001).ConclusionIn patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.

Introduction and Objectives. Patients with dilated cardiomyopathy (DCM) and functional mitral regurgitation (FMR) present altered geometry and dynamics of the mitral annulus (MA). We aimed to further assess the relationship between the MA dysfunction, FMR severity, and LA dysfunction in patients with ischemic and nonischemic DCM by using three-dimensional transthoracic echocardiography (3DTTE). Methods. 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. Results. Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p<0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p<0.05). MAFAC correlated inversely with EROA and Rvol (r = −0.32 and r = −0.35, p<0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. Conclusions. Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

Advanced pharmacologic and interventional therapies have improved survival in heart failure. Implantable cardioverter-defibrillators (ICD) have been shown to reduce mortality in patients with heart failure, but the benefit appears to be uneven in this population. We reviewed the evidence showing the benefit of ICD therapy in heart failure patients, the main issues arising from these studies, and the possible answers for a better risk stratification. In addition, we showed that multimodality imaging could improve patient selection for the implantation of ICDs, in both primary and secondary prevention, beyond the selection using only the left ventricular ejection fraction, by concentrating on arrhythmic substrate.