Background: None of the currently available prosthetic valves are comparable to native valves in hemodynamic functions. One has to choose between durability, thrombogenicity, or risk of major bleeds. These questions can be answered effectively with the help of long-term follow-up data. Aims and Objectives: We aimed to assess primary and secondary outcomes in patients who had undergone valve replacement (bioprosthetic or mechanical) over the last 15 years at our institution. Materials and Methods: Retrospective data on clinical outcomes of all patients of valve replacement surgery over the last 15 years was taken. Standardized definitions were used to report primary and secondary outcomes, and appropriate statistical methods were applied to evaluate the data. Results: There were a total of 681 patients (66.7% mechanical and 33.3% bioprosthetic valves) with a median follow-up of 7.5 years. Overall survival rates for bioprosthetic valves for 1,5, and 10 years were 99% and for mechanical valves were 98% and 96% at 5 years and 10 years respectively. Late mortality predictors in the mechanical valve group were pre-operative New York Heart Association (NYHA) class, left ventricular (LV) systolic function, atrial fibrillation, post-operative sub-therapeutic international normalized ratio (INR) values and valve replacement at mitral position. Conclusion: The study showed that mechanical valves had a 96 % survival rate at 10 to 15 years which was dependent upon preoperative NYHA class, preoperative LV functions AF, and postoperative INR values. In contrast, bioprosthetic valves had 99% survival but with a higher incidence of secondary outcomes, mainly in the form of structural valve degeneration.

Background: Two-dimensional speckle-tracking echocardiography (2D-STE) is a newer method for assessing left ventricular (LV) systolic function. The aim of this study was to assess the predictive value of 2D global longitudinal strain (GLS) in the detection of longitudinal LV systolic dysfunction and the identification of significant coronary artery disease (CAD) in non-ST-segment elevation myocardial infarction (NSTEMI) patients without wall motion abnormalities. Materials and Methods: We enrolled 100 patients who were suspected cases of NSTEMI with echocardiography showing LV ejection fraction >50% and no regional wall motion abnormality. LV myocardial function was assessed using conventional echocardiographic measurements and myocardial deformation analysis with 2D-STE. The patients found to have significant CAD on coronary angiography were included in the cases group and those without significant CAD were considered as controls. Results: Mean age of the patients was 58.36 ± 11.21 years versus 56.54 ± 8.10 years in controls. Male preponderance was found in both case and control groups, with 66% (n = 33) and 56% (n = 28) males, respectively. The patients had significantly lower GLS as compared to the controls (-16.31 ± 1.34% vs -19.17 ± 1.63%, P < 0.001). The patients with positive troponin assay had a lower mean GLS −16.49 ± 1.5% as compared to those with negative troponin assay (−19.32 ± 1.54%, P < 0.001). Multivariate analyses indicated that GLS was an independent predictor of CAD in those with NSTEMI (GLS odds ratio = 0.024, P < 0.001). Conclusions: The present study demonstrates that 2D-STE is superior to conventional echocardiography in excluding significant CAD. It is a promising, easy to perform, bedside tool for diagnosis and prognostication in patients with NSTEMI. GLS has a potential to be used in conjugation with other risk stratification strategies to identify patients at high risk.

Introduction: A large number of pregnancies are complicated by diabetes mellitus in the mother which is associated with the risk of various cardiac structural and functional complications in the neonates. A diagnostic tool is needed to detect these dysfunctions early. In contrast to conventional pulsed-wave Doppler, which is influenced by heart rate and the impact of volume changes on transmitral flow, tissue Doppler imaging is the mode of echocardiography that is relatively independent of the loading state. Two-dimensional (2D) speckle-tracking echocardiography-derived strain imaging is a new technology increasingly being used to estimate cardiac systolic and diastolic dysfunction and has superior prognostic value for predicting major adverse cardiac events. Objective: The objective of this study was to evaluate cardiac function in neonates of mothers with diabetes on echocardiography and differences in the extent of cardiac dysfunction between neonates of well-controlled and poorly controlled mothers with diabetes. Methods: This is a cross-sectional observational study which was done on 152 neonates born to mothers with diabetes (22 overt vs. 130 gestational and 23 well-controlled vs. 129 poorly controlled) and 96 born to nondiabetic mothers. Three modes of echocardiography, i.e. M-mode, Doppler (pulsed wave and tissue), and 2D speckle-tracking echocardiography, were done and cardiac functions were compared among different groups. Results: Infants of diabetic mothers (IDMs) had lower ejection fraction on M-mode echocardiography and lower values of global longitudinal strain on 2D speckle-tracking echocardiography along with significantly lower values of mitral and tricuspid E velocity and E/A ratio with higher values of A velocity on pulsed-wave Doppler. Tissue Doppler showed higher left ventricle E/E' in IDM implying more systolic as well as diastolic dysfunction in IDM as compared to non-IDM. In neonates born to mothers with poorly controlled diabetes, Doppler showed lower values of mitral and tricuspid E/A ratio and left ventricle E'/A' ratio signifying more diastolic dysfunction as compared to neonates born to mothers having good glycemic control. Similarly, neonates born to mothers with pregestational diabetes had significantly deranged systolic and diastolic functions. Conclusions: IDMs have significant cardiac dysfunction on echocardiography which is also related to the degree of glycemic control and onset of diabetes.

Background: The assessment of myocardial function is important in both primary and secondary mitral regurgitation (MR), to determine the timing of interventions and to predict outcomes. Ejection fraction is relied on for clinical decisions, even though, it is well understood that it does not reflect myocardial function. Global longitudinal strain (GLS) is a promising parameter that correlates well with outcomes postinterventions. In this review, we aimed to determine the utility of GLS in both primary and secondary MR in predicting clinical outcomes. We also aimed to determine the GLS cutoff at which clinical decisions can be made. Methods: We conducted a systematic review of the literature regarding the use of GLS as a predictor of left ventricular (LV) function. We searched PubMed and Embase for relevant articles and identified 141 articles after removing duplicates. We screened titles and abstracts to identify 28 relevant articles from which data were extracted. Results: In 16 of the 28 studies, patients had primary MR mostly of degenerative etiology and the LV GLS cutoff for events ranged from −17.2% to −21%. In 10 studies, patients with secondary MR were included, and a cutoff ranging from −7%− to −9% was most often reported except for one study that reported-16.3%, as it included patients with atrial functional MR. Conclusion: GLS assesses LV dysfunction and is a good predictor of clinical and echocardiographic outcomes postinterventions. Values lower than the cutoff value of −17.2% to −21% in primary MR and −7% to −9% in secondary MR are associated with poorer outcomes. These findings suggest that the use of GLS as a routine assessment in patients with significant MR may be appropriate for both clinical decision-making and prognostication.

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome of effort intolerance based on structural and functional abnormalities of the cardiovascular system (CVS). Its prevalence is increasing progressively in comparison to that of heart failure with reduced ejection fraction due to aging, obesity, metabolic stress, and hypertension. Multiple domains of the CVS and peripheral organs have reduced reserve capacity and increased stiffness in patients with HFpEF. This high-gain CVS exhibits increased filling pressures and reduced filling volumes under stress despite the left ventricular ejection fraction, commonly estimated parameter of contractile performance, being normal, i.e., >50%. The cost of increasing cardiac output in terms of left ventricular filling pressures is increased and their relationship shows an upward and more left-directed slope due to reduced ventricular and arterial compliance. At the tissue level, there is myocytic hypertrophy and increased extracellular matrix with capillary rarefaction. There are many phenogroups of HFpEF based on the heart's ability to secrete natriuretic peptides, degree of dysmetabolism, age, renal function, body fat, rhythm, underlying etiology, and subclinical systolic dysfunction. The left ventricle may be pressure-loaded, volume-loaded, or have equipoise with regard to remodeling. Myocardial performance estimated by parameters other than those based on distance or volume displacement may be abnormal in more than half of the patients underlying the presence of subtle systolic dysfunction. This review looks at myocardial performance and characteristics in HFpEF by deformation imaging using acoustic speckle tracking and its diagnostic and prognostic significance. Research points toward the utility of global longitudinal strain in early detection, biological characterization, and risk stratification of HFpEF. Echocardiographic speckle-tracking-based longitudinal strain analysis represents a method of relatively high value and for sensitive phenotyping of HFpEF which is yet to be utilized optimally. Other dimensions of strain, although extensively studied in HFpEF, do not add much value. The focus is on systolic deformation since there is limited utility of diastolic strain and its rate.

Although aortic stenosis (AS) is a disease of poor outcomes, timely aortic valve replacement [AVR -surgical AVR (SAVR) or transcatheter AVR (TAVR)] improves the outlook with acceptable procedural risk. Survivors of AVR enjoy life expectancy that is like that of age matched controls. AVR receives a class I indication from the American and European Guidelines, in the presence of symptoms attributable to AS or when left ventricular (LV) systolic dysfunction manifests. However, there are fallacies in timing the intervention based on symptoms or LV ejection fraction. If surgery is delayed till symptoms manifest or LV dysfunction occurs, surgical risks are increased, long term outcomes are poor and in half of the patients, LV function never normalizes. Because of these reasons, pre-emptive intervention based on non-conventional parameters is expected to save more lives and prevent LV dysfunction. Data are emerging towards this approach and researchers have started focussing their attention on biomarkers like brain natriuretic peptide, multimodality imaging like estimation of extracellular volume by cardiac magnetic resonance for choosing the appropriate time for intervention in asymptomatic individuals. A relatively inexpensive way of identifying such high-risk individuals is speckle tracking imaging and in the last decade sufficient data have accumulated in favour of this modality to identify patients who may be benefited by early intervention. Speckle tracking echocardiography is a well validated technique which enables highly reproducible, angle-independent assessment of regional and global LV systolic function in longitudinal, circumferential and radial planes. Longitudinal strain, which is predominantly governed by the subendocardial layer, is most sensitive in the presence of myocardial disease and well-studied. Moreover, when discrepancies occur between gradient and valve area leading to uncertainties about the severity of AS, strain imaging would be of value in predicting outcomes particularly in those with low flow low gradient AS with normal LV ejection fraction.

Two-dimensional strain imaging has an established role in the detection of subtle or subclinical left ventricular (LV) dysfunction in cardiomyopathies. The application of strain imaging, particularly longitudinal strain (LS), is emerging as a simple yet powerful tool in the detection of the early decline of LV function in valvular heart diseases also, including aortic regurgitation (AR). The advantages of strain imaging include its simplicity of the concept and imaging technique, its rapidity, and less interpersonal variability. The detection of lower strain values may help the clinician to optimally time the surgical intervention among asymptomatic individuals with preserved ejection fraction (EF). Such a preemptive approach is expected to improve the surgical results and offer better outcomes in terms of longevity and reverse remodeling of LV. Numerous studies have confirmed that a global LS value of 19.5% is the ideal cutoff for the detection of early LV dysfunction in AR. It has been shown in studies that a decreased strain correlates with mortality in medically treated as well as in operated patients. Apart from being potentially helpful in the timing of surgery in asymptomatic individuals, the estimation of strain is also useful in the detection of the contractile reserve, which is translated into better postoperative outcomes. If this finding is supported by future studies, strain imaging may eventually replace stress echocardiography in evaluating asymptomatic patients with valve diseases. Even in patients with advanced disease and low EF, strain values are helpful in identifying the subset of individuals who show better response to surgery. A cutoff of 12% appears to be useful in the detection of responders in this high-risk group. The usefulness of radial and circumferential strain, apical and basal rotation, and layered strain remains to be established. The extension of strain measurements in assessing myocardial work appears to be an attractive option for assessing LV function without load dependency.

Systemic diseases consist of various pathological conditions with a wide range of symptoms, often with progressive clinical worsening. Cardiac involvement is not uncommon in many of these conditions. Subclinical myocardial dysfunction is the common manifestation during the early stages of the disease and recognition of early myocardial dysfunction is very important for diagnosis and future prognosis. Left ventricular ejection fraction (LVEF) is considered less sensitive to detect early LV myocardial dysfunction. Strain imaging, performed using speckle-tracking echocardiography (STE), has emerged as a robust tool for detecting early subclinical myocardial dysfunction. The longitudinal muscle fibres are predominantly found in the sub-endocardium and are more susceptible to damage since the sub-endocardium is comparatively less perfused. Hence, longitudinal strain is impaired early in the course of the disease and helps in detecting subtle cardiac involvement in various systemic diseases. Global longitudinal strain, which is the average longitudinal strain of all the LV myocardial segments, is currently the most useful strain parameter for this purpose.

The potential utility of strain imaging as a tool for quantitative assessment of myocardial contractile function has already been demonstrated in many cardiac conditions. Numerous studies have explored its utility in patients with coronary artery disease (CAD) also. Almost the entire spectrum of CAD has been studied and several different strain parameters and indices derived from global or regional longitudinal, circumferential, radial and area strain as well as left ventricular rotation have been employed. These studies have mostly shown that strain imaging can have an incremental role in the diagnosis and prognosis assessment of CAD. However, a few important limitations are there. Most importantly, CAD involves the left ventricle in a segmental manner and unfortunately, segmental strain at present has significant measurement variability rendering it unsuitable for routine clinical use. Nevertheless, strain imaging has many potential uses in CAD. This review describes the current understanding about the role of strain imaging in the evaluation and management of CAD.

Several cardiac conditions are associated with the risk of ventricular arrhythmias (VAs) and sudden cardiac death (SCD). Identification of the individuals at increased risk of these events is essential to facilitate the appropriate measures to prevent SCD. Several clinical, electrocardiographic, and imaging markers have been used for this purpose with varying accuracy. Recently, longitudinal myocardial strain assessed using speckle-tracking echocardiography has been shown to have incremental value in the prediction of SCD risk. Strain imaging allows quantification of the abnormalities in the magnitude and timing of the segmental myocardial contraction, which is a surrogate for underlying myocardial fibrosis and myofiber disarray. Reduced segmental strain and temporal heterogeneity indicate electromechanical dispersion, which is the primary substrate for VAs and SCD. This review summarizes current evidence regarding the utility of longitudinal strain for the prediction of SCD risk.

Lack of therapeutic response in nearly 30% of patients undergoing cardiac resynchronization therapy (CRT) remains a major therapeutic challenge. Given the role of echocardiography in detecting mechanical dyssynchrony, extensive research has been undertaken to identify the echocardiographic predictors of CRT response. After the initial setback, the interest in this field has renewed with the introduction of speckle-tracking echocardiography (STE) for quantifying myocardial deformation. Several newer and potentially useful indices of mechanical dyssynchrony have been developed. In addition, the non-invasive assessment of myocardial work has also become feasible and many of the myocardial work indices have shown considerable promise in the initial studies. The strain imaging may also help in identifying the optimum site for left ventricular lead placement. This review summarizes the current understanding regarding the role of left ventricular strain imaging in patients undergoing CRT.

Prognosis in cardiac disorders is determined by left ventricular (LV) function and hence, its precise estimation is of utmost importance. Myocardial work is a new advanced technique based on computation by incorporating systolic blood pressure into strain analysis. The aim of this review article is to provide an overview and additive value of this technique for the assessment of LV systolic function. The article includes the evolution of this technique from invasive to noninvasive mode, the method of acquiring and measuring it, normal reference values, its role in various cardiac conditions as described in the current literature, and potential limitations.

For many decades assessment of right ventricular function has been a challenge, with several parameters available for use but none being reliable and accurate. The oldest and still the most widely used is tricuspid annular plane systolic excursion (TAPSE), which has its own technical limitations. Later, the arrival of tissue Doppler imaging provided an additional parameter, with its measurement of peak systolic velocity of the lateral annulus of the tricuspid annulus, but this being angle-dependent also showed limited utility, like TAPSE. The advent of speckle-tracking echocardiography over the last decade, which is not angle-dependent and less load dependent, heralded a new way of looking at the RV function landscape. Despite some technical challenges, it has shown itself to be acceptable and has increasingly been used as a reliable parameter in clinical settings over the last few years. It has been recommended as a parameter with high feasibility and reproducibility.

Left ventricular (LV) diastolic pressure estimation is essential for characterization of heart failure. Despite extensive research and the availability of numerous metrics, the assessment of LV diastolic pressures both at rest and after exertion has been challenging. Left atrial strain assessment by echocardiography has recently shown promise in correlating with LV end-diastolic pressure. This review provides information about this novel technology.

Truncus arteriosus (TA) is a congenital cyanotic heart disease with admixture physiology at the great arterial level. It can have associated anomalies of the pulmonary arteries, truncal valve narrowing, etc., Total pulmonary venous anomalous drainage associated with TA is extremely rare. We report a sick young infant who presented with type I TA and obstructed infracardiac total anomalous pulmonary venous return.

This case report describes a 69-year-old male who presented with acute anterior myocardial infarction and was detected to have a hyperdominant right coronary artery (RCA) with a large posterior descending branch coursing from the posterior interventricular groove into the apical part of the anterior interventricular space and posterior left ventricular branch coursing in the left atrioventricular groove and supplying the entire free wall. Primary percutaneous intervention of the proximally occluded posterior descending artery resulted in resolution of ST-segment elevation in anterior and inferior leads and also revealed the large vascular territory of the RCA. The occurrence of superdominant RCA and intact left circumflex artery presenting with acute anterior wall myocardial infarction has not been described earlier. Precise morphological and physiological knowledge and evaluation of such a variation assists in opting for the best available therapeutic modality and prognosis.

This report describes a 68-year-old female who, immediately after the primary percutaneous coronary intervention of the left anterior descending artery for acute anterior myocardial infarction, developed an apical aneurysm and a “neo-chamber” within the left ventricular cavity separated from the main cavity by a linear thick hyperechoic free-floating fenestrated membrane. This was an excoriated but perforated subendocardial spiral myocardial layer separated from the subepicardial layer due to ischemia and infarction. Multiple orifices on the inner surface were observed, possibly due to patchy necrosis. In addition, there was a large remote intramyocardial hematoma in the inferolateral wall of indeterminate pathogenesis.

A 27-year-old male was admitted with dyspnea of sudden onset and was initially diagnosed to have acute pulmonary embolism, bilateral pleural effusion, and mild pericardial effusion. Detailed echocardiographic examination revealed echocardiographic features of constrictive pericarditis (CP), marked spontaneous contrast in inferior vena cava, and a right atrial thrombus. The patient had bilateral lung consolidation and pleural effusion presumably of tubercular origin. Intracardiac thrombi are rare in patients with CP and may impact prognosis and management strategy.

A 63-year-old female with hypertension, evaluated for atypical chest pain and continuous precordial murmur, was found to have an insignificant stenosis in the proximal right coronary artery with a large tortuous fistula originating from the right sinus of Valsalva to the coronary sinus draining into the right atrium with an unusual course parallel to but distinct from the right coronary artery. Multidetector computed tomographic coronary angiography and cardiac catheterization confirmed the diagnosis. Such an anomaly has not been reported earlier.