Following two-years of being held virtually, it was a pleasure to welcome delegates to the first ever hybrid annual conference of the British Society of Echocardiography (BSE) in October 2022. This was held at the prestigious Queen Elizabeth II Conference Centre in the City of London, with fabulous views directly out over Westminster Cathedral and the Houses of Parliament.After virtual conferences enabled two consecutive years of recording breaking attendance, it was a pleasure to welcome a total of 1300 attendees, including nearly 600 in person and 24 exhibitors and representatives from all the major echocardiography companies.Lectures were spread over three auditoria during the conference with parallel sessions providing plenty of options for all delegates, including a stream dedicated entirely to trainee echocardiographers. In addition, there were live in-person sessions during the breaks providing delegates with the opportunity to gain insight from leading researchers in the field of echocardiography.The right assessment: Utilising novel atrial markers to support pulmonary hypertension investigation.We were delighted to welcome Professor Otto Smiseth as our international guest speaker for BSEcho 2022. Professor Smiseth is a world-leading expert in the imaging of heart failure and provided an outstanding lecture on current trends and emerging techniques for the assessment of patients in heart failure with preserved ejection fraction. The Investigator of the Year award for 2022 was won by Dr James Willis for his investigation: Prior to the meeting all members of the British Society of Echocardiographers were invited to submit abstracts which were then scored and shortlisted by an expert panel for originality, overall quality, significance and level of interest. Our thanks to the members of the panel: Dr Maria Paton; Dr Dave Oxborough; Dr Liam Ring; Dr Aimee Drane and Dr James Malcolmson for all their work in reviewing the abstracts.The 2023 conference will take place on the 13th and 14th of October in Cardiff, at the International Conference Centre Wales. We are delighted to welcome Professor Judy Hung, director of echocardiography at Massachusetts General Hospital in Boston, and Professor Sanjay Sharma, professor of cardiology at St Georges Hospital in London, as our international and invited speakers. We look forward to seeing you there!Echo Research & Practice 2023, 10(Suppl 1):ABS001Background: Heritable cardiac diseases cause significant morbidity and mortality. A Service Evaluation of the York Hospital screening program, which utilises echocardiography for diagnosis, was undertaken. The Positive Predicative Value (PPV) of a family history (FH) for heritable cardiac disease was investigated to evaluate the screening program.Methods: Records of patients referred to the Cardio-Respiratory department for a FH of Bicuspid Aortic Valve (BAV), Aortopathy, Hypertrophic Cardiomyopathy (HCM) or Dilated Cardiomyopathy (DCM) between 2010 and 2021 were examined. Patients with a positive echocardiogram report for the pathology being screened for were classed as True Positives. This allowed the PPV for FH of each condition to be calculated.Results: PPV for FH of DCM, BAV and HCM were low  and 6% (95% CI [2–10]) respectively). Aortopathy had a higher PPV overall at 22% (95% CI [8.6–35.8]). Ages of the True Positives were significantly higher than the False Positives for both aortopathy and HCM . Comparing disease prevalence in the study population to the general population showed that BAV prevalence was not significantly different (p = 0.52) whereas aortopathy and HCM prevalence’s were significantly higher than the general population . Male gender (p = 0.0101), 1st degree proband (p = 0.0101) and being > 45 years old (p = 0.002) were significantly associated with the True Positive aortopathy group and being > 45 years old was significantly associated with True Positive HCM group (p = 0.029).Conclusion: Analysis of the BAV and DCM data is limited by sample size. For HCM and aortopathy this data supports that initiating screening later in life could improve the efficacy of screening. The characteristics found to be significantly associated with True Positives could inform a prospective study.Echo Research & Practice 2023, 10 (Suppl 1):ABS002Background: The assessment of right ventricular (RV) contractile reserve (CR) during exercise echocardiography in healthy subjects is not well described. We aimed to describe normal RV CR in healthy cases and to compare CR to patients with defined RV compromise because of previous repair of Tetralogy of Fallot.Methods: 40 healthy individuals with satisfactory RV windows were randomly selected and retrospectively analysed from previously published study (marathon study). These cases were compared to 100 adult patients with repaired TOF. We defined RV CR by the change in tricuspid lateral annular systolic velocity (ΔRVS’), change in tricuspid annular plane systolic excursion (ΔTAPSE), and change in fractional area change (ΔFAC). All parameters were evaluated at baseline and at peak stress.Results: During exercise, RVS’ was increased by 60 ± 20%, followed by TAPSE 48 ± 15%, and the lowest with FAC by 32 ± 10%. These ranges were significantly higher than in TOF population. RV CR was greater in males than females for all RV functional measures ; ; , for ΔFAC, ΔTAPSE, and ΔRVS’, respectively. There was no association between RV CR and functional capacity parameters in healthy individuals, whereas in patients with repaired TOF there was a significant association with peak absolute VO2 (ml/min) .Conclusion: We have presented normal values for RV CR parameters in healthy cases during stress echocardiography. RV CR is an important determinant of exercise capacity in patients with abnormal RV function but not in normal subjects.Echo Research & Practice 2023, 10 (Suppl 1):ABS003Background: The use of 2D and 4D during stress echocardiography to undertake complex measures in complex patients like patients with repaired TOF is challenging and the validity of these measures is not known yet.Methods: For test–retest variability, 20 patients with repaired TOF with no or mild pulmonary regurgitation were selected randomly and underwent a cardiopulmonary exercise test (CPET) with echocardiography. Intra-observer variability study was performed for all 20 patients by the same observer. Interobserver variability study was performed for 5 patients by different experienced observer. Intraclass correlation coefficient (ICC), and coefficients of variation (COV) were used to quantify reproducibility and variability.Results: For 2D measures, better reproducibility was observed for semiautomated 2D strain measures than 2D functional measures for biventricular systolic function at baseline and during the stress , with least COV was observed (COV < 10%). 4D semiautomated volumetric measures demonstrated less reproducibility during stress with highest COV was observed for 4D RV volume parameters , followed by 4D LV volume parameters . CPET had an excellent agreement of all measures (ICC > 0.90) with very low COV (< 10%).Conclusion: Semiautomated echo measures outperformed manual measures during stress echocardiography and can be performed with acceptable reproducibility. Variability is at highest for 4D semiautomated measures despite good reproducibility, while lowest variability was observed for 2D semiautomated measures of myocardial deformation.Echo Research & Practice 2023, 10 (Suppl 1):ABS004Background: Identifying exercise determinants in patients with repaired Tetralogy of Fallot (rTOF) is complex. We sought to investigate exercise performance and to identify the best exercise predictors.Methods: We prospectively recruited 100 patients with rTOF, 60 patients with severe PR (SPR), and 40 patients with no PR (controls). All patients underwent cardiopulmonary exercise testing with echocardiography. Right ventricle (RV) contractile reserve (CR) was defined by the change in peak systolic velocity (ΔRVS’), and change in fractional area change (ΔFAC). Left ventricle (LV) CR was defined by the change in systolic function (ΔLVS’), and change in global longitudinal strain (ΔLVGLS).Results: There was no significant difference in the reduced exercise performance between the SPR and control groups by peak absolute oxygen consumption VO2. During exercise, lower RV CR was observed in the SPR group by ΔRVS’ ; and ΔFAC , while it was greater for LV CR by ΔLVS’. Change in ΔLVGLS was the same . There were no associations between exercise measures with the degree of PR and RV volumes at rest and during exercise. Augmentation of LVGLS and FAC were shown independent associations with peak VO2.Conclusion: there was an overall marked reduction in exercise capacity but not a difference between those with and without PR. The degree of exercise limitations is more dependent upon the ability of RV and LV to augment longitudinal function rather than to severity of PR.Echo Research & Practice 2023, 10 (Suppl 1):ABS005Background: Assessment of LV myocardial work (MW) and biventricular mechanical dispersion (MD) in patient with repaired TOF (rTOF) is novel. We sought to investigate the LV MW and biventricular MD response during stress echocardiography.Methods: We analysed MW and MD at baseline and at low exercise intensity for 100 adult patients with repaired TOF, 60 patients with severe pulmonary regurgitation (SPR), and 40 patients with negligible PR (NPR). MW was derived as the area of pressure strain loop using speckle tracking echocardiography and blood pressure. MD was derived as the SD of time Q/R wave on ECG to peak longitudinal strain and expressed in millisecond.Results: Reduced MW indices were observed in the entire population with mean global work efficiency (MWE) was 85 ± 7%. Overall mean of global work index (GWI) was 1198 ± 312 mmHg%, 1701 ± 303 mmHg% for global constructive work (GCW), and 293 ± 194 mmHg% for global wasted work (GWW). The SPR group had lower MWE, lower GCW and higher GWW. During exercise, overall ΔMWE decreased by − 2 ± 10%, ΔGWI increased by 36 ± 43%, ΔGCW increased by 68 ± 40%, and ΔGWW increased by 120 ± 110%. Overall resting mean value of RVMD was 46 ± 18,ms, while 64 ± 11,ms for LVMD, and higher values were observed during exercise. Changes in MWE, MWW, and LV and RVMD were closely associated with peak oxygen uptake .Conclusions: LV MW indices are reduced and biventricular MD are pronounced in rTOF patients. Augmentation of MW parameters and timing were associated with objective exercise ability, suggesting that they are potential determinants of cardiopulmonary capability.Echo Research & Practice 2023, 10 (Suppl 1):ABS006Background: Many patients with heart failure, particularly that associated with hypertension, have preserved ejection fraction (HFpEF) where impaired relaxation is thought to be the primary cardiac abnormality. However, early systolic dysfunction could also be an important feature of HFpEF.Aims: We examined the relationship of early systolic function as measured by first-phase ejection fraction (EF1) to diastolic function and whether EF1 predicts adverse outcomes  in patients with HFpEF.Methods: EF1 was measured in hypertensive subjects with no evidence of heart failure, but with varying degrees of diastolic dysfunction and in patients with HFpEF. The relationship of EF1 to diastolic function under resting conditions and after an acute intervention to reduce cardiac pre-load was examined.Results: There was a progressive impairment of EF1 with degree of diastolic dysfunction . An acute reduction in cardiac pre-load resulted in an increase in EF1 which correlated with an improvement in E/e’ (p < 0.01). In 177 HFpEF patients followed for a median of 19.3 months, there were 40 deaths and 61 re-hospitalisations. EF1 was the most powerful predictor of events  and improved the C-statistic over a model incorporating age, BMI, stroke, COPD, end-diastolic volume, arterial and ventricular elastance (p < 0.001).Conclusion: Early systolic dysfunction may be a major determinant of outcome in HFpEF, is at least partially reversible, and a potential target for therapy.*Zhenxing Sun, Yu Cai and Yujia Yang are co-first authors†Li Zhang, Mingxing Xie and Haotian Gu are Co-senior authorEcho Research & Practice 2023, 10 (Suppl 1):ABS007Background: First-phase ejection fraction (EF1) is a novel measure of early systolic function. This study was to investigate the prognostic value of EF1 in heart transplant recipients.Methods: Heart transplant recipients were prospectively recruited consecutively at the Union Hospital, Wuhan, China between January 2015 and December 2019. All patients underwent clinical examination, biochemistry measures [brain natriuretic peptide (BNP) and creatinine] and echocardiography. The primary endpoint was a combined events of all-cause mortality and graft rejection.Results: In 277 patients (aged 48.6 + 12.5 years) followed for a median of 38.7 (interquartile range: 18.3) months, there were 35 (12.6%) patients had adverse events. EF1 was associated with BNP  and was significantly lower in patients with events compared to those without. EF1 had the largest area under the curve in ROC analysis compared to other measures. A cut-off value of 25.8% for EF1 had a sensitivity of 96.3% and a specificity of 97.1% for prediction of events. EF1 was the most powerful predictor of events with hazard ratio per 1% change in EF1: 0.628  after adjustment for ejection fraction and global longitudinal strain.Conclusion: Early systolic function as measured by EF1 is a powerful predictor of adverse outcomes after heart transplant. EF1 may be useful in risk stratification and management of heart transplant recipients.Echo Research & Practice 2023, 10 (Suppl 1):ABS008Background: Pericardial effusions (PE) occur when there is an excess of fluid accumulating within the pericardial space. We have observed an increase in the number of PE’s detected amongst all transthoracic echocardiography (TTE) scans performed since the start of the COVID-19 pandemic irrespective of cause for referral. This is interesting given that the most common cause of PE’s in the Western World is considered to be post-viral infection.Aims: Validate a significant increase in the rate of PE detection via TTE from January 2020-December 2021 compared to the previous 3 years and compare PE detection with national COVID-19 infection data.Methods: All TTE scans performed between January 2017 and December 2021 were utilised to generate rates of PE detection. A t-test was performed to assess for a significant difference in PE detection pre-COVID-19 (January 2017-December 2019) and during the pandemic (January 2020-December 2021). Data on the incidence of COVID-19 cases in the UK was gathered from the Gov.uk website.Results: A total of 37,069 TTE’s were performed pre-COVID-19 and 24,125 scans post-COVID-19. Majority of the 2020–2021 TTE’s were performed in low risk COVID-19 patients. There were significantly more PE’s detected post-COVID-19 compared with pre-COVID-19 with rates of detection of 0.14 and 0.05 respectively (p < 0.001). Detection of PE’s increased from 2017–2021, despite a decrease in total scans performed post-COVID-19 . Comparison with national COVID-19 infection data shows a peak in PE incidence following a peak in infections .Conclusion: We have noticed a significant increase in PE detection since the start of the COVID-19 pandemic. This appeared to track the incidence of national COVID-19 infections.Echo Research & Practice 2023, 10 (Suppl 1):ABS009Background: Left atrial (LA) function is a novel cardiovascular imaging biomarker, but the agreement of different techniques and reproducibility is not known.Aims: We aimed to investigate: (i) The inter-technique agreement and (ii) The test–retest reproducibility of both transthoracic echocardiography (TTE) and cardiac MRI (CMR) derived LA strain (LAS) and volumetric assessment in people with and without cardiovascular disease.Methods: 192 participants were recruited: Asymptomatic Type 2 diabetes , severe aortic stenosis (n = 65) and healthy volunteers (n = 53) had TTE and CMR on the same day for inter-technique agreement. Another ten participants with T2D had both scans repeated 11 ± 4 days later for test–retest reproducibility. TTE images were analysed using TomTec-ARENA (v2.4) and Medis Suite (v3.1) for CMR images. All analyses were performed by a single-blinded operator using identical techniques for TTE and CMR: LA volumes and emptying fraction (EF) were quantified using biplane area-length method. LAS corresponding to LA reservoir, conduit, and booster pump was calculated using the average of 4- and 2-chamber values.Results: As shown in Table 1, TTE and CMR agreement was moderate (ICC 0.55–0.69) for LAEF and strain parameters. CMR reproducibility was good to excellent for LA volumes, EF, reservoir and booster pump-LAS, whilst on TTE LA volumes and conduit-LAS had good reproducibility .Conclusion: There is a modest agreement between TTE and CMR for LA function assessment. Conduit-LAS is more reproducible on TTE. LAEF, reservoir and booster pump-LAS are more reproducible on CMR, suggesting the use of CMR in assessing LA function in longitudinal studies.Echo Research & Practice 2023, 10 (Suppl 1):ABS010Background: In 2020, the British Society of Echocardiography (BSE) produced updated normal reference ranges for the aortic root and ascending aorta. After implementation, clinicians at Newcastle upon Tyne NHS Foundation Trust noticed increasing numbers of reports with “aortic root dilatation” and were unsure how to proceed.Aims: In March 2022 we conducted an audit to determine the numbers of patients with a report of a dilated aortic root/ascending aorta according to the new BSE criteria.Methods: We selected 100 consecutive patients from the local echo database with height documented. Absolute and indexed measurements were noted for the aortic sinuses, sinotubular junction, and ascending aorta. Age, sex, valve morphology, family history of aortopathy, hypertension, and other cardiovascular risk factors were obtained from electronic records.Results: 28% of patients had aortic root and/or ascending aorta dilatation . Mean age was 69 years and 61% were male. Within the cohort with dilatation, 25 had tricuspid aortic valves , 64% had hypertension, and 56% had other cardiovascular risk factors. One had a family history of aortopathy. The vast majority of dilatation occurred in patients aged over 60 years and with an absolute aortic dimension < 40 mm .Conclusion: NORRE reference intervals would allow for 2.5% of healthy people to have aortic roots/ascending aortas above the normal range. Patients are not normal by definition and may have predisposing conditions causing aortic dilatation. What requires surveillance in this setting is not clear, but a 28% surveillance rate is not sustainable for current services. A regional strategy to rationalise this is being ratified. A national response needs consideration.https://echo.biomedcentral.com/track/pdf/10.1530/ERP-19-0050.pdf [Accessed 17th July 2022].Harkness, A., Ring, L., Augustine, D., Oxborough, D., Robinson, S. and Sharma, V on behalf of the Education Committee of the British Society of Echocardiography (2020) Normal reference intervals for cardiac dimensions and function for use in echocardiographic practice: a guideline from the British Society of Echocardiography [pdf] Available at: Echo Research & Practice 2023, 10 (Suppl 1):ABS011Background: Inappropriate use of echo wastes resources, and unnecessarily medicalises patients, potentially triggering an unnecessary cascade of investigations, with its attendant risks, expenditure and anxieties. We audited our practice to determine whether we could improve service quality by ensuring compliance with the British Society of Echocardiography (BSE) list of appropriate indications for transthoracic echo. We focused on referrals to ‘assess left ventricular (LV) function’ since this is one of the most common indications.Aims: To evaluate whether:Individuals triaging primary care referrals adhered to BSE-appropriate indications for echo.Referrals not meeting appropriateness criteria were associated with a clinically significant result.Methods: Clinical audit of 263 echo referrals from GPs (Jul 21-Feb22). Referrals were triaged by healthcare scientists and cardiologists in the local health board. Referrals with clinical evidence of disease, abnormal ECG ± abnormal NT-pro-BNP were considered appropriate. The following were considered inappropriate: minor radiographic cardiomegaly in the absence of symptoms/signs of heart failure; peripheral oedema but normal venous pressure and no evidence of cardiac disease; asymptomatic hypertension where echo would not change management. We reviewed the echo report for inappropriate referrals to determine whether there was any significant LV impairment.Results: Complete information was obtained for 253 patients . 93 (37%) were to ‘assess LV function’ and constituted the study population. Clinical characteristics included hypertension (60%), breathlessness (54%), and peripheral oedema (33%). 69 (74%) of referrals were appropriate, 20 (22%) were inappropriate, 4 (4.3%) could not be classified. No patient in the ‘inappropriate’ group had impaired LV function but only 4(20%) were reported as normal examinations. 12 (60%) reports included abnormal LV geometry ±borderline function, 4 (20%) had mild valve disease.Conclusions: A significant proportion of echo referrals to evaluate LV function were accepted in triage despite not meeting nationally accepted appropriateness criteria. These are adding to service burden and waiting times. Inappropriate referrals may produce echo findings that could be considered abnormal by GPs but may not be clinically relevant to patient presentation. We need to improve knowledge of appropriate use criteria among local GPs and those performing triage.Echo Research & Practice 2023, 10 (Suppl 1):ABS012Background: Prudent healthcare requires us to prioritise those with greatest need, to do just what is needed—no more and no less. Anecdotal evidence from echocardiographers suggested that many referrals from GPs were to exclude significant disease. Level 1 echo provides a limited dataset to answer a clinical question, but it is not currently recommended for primary care. We performed a retrospective analysis of stored echo data to explore the potential utility of level 1 echo in a primary care service.Aims: To identifyThe proportion of GP referrals which may be resolved by a level 1 scan.Whether an echocardiographer can accurately determine when to progress to a level 2 scan.Whether significant pathology is missed when the level 1 scan is deemed sufficient.Methods: A random sample of 31 patients was drawn from 263 patients referred by GPs (Jul 21-Feb22). Anonymised echo images and reports were reviewed by a Clinical Scientist (echo), before a level 1 dataset was saved to a DVD. A second echocardiographer, blind to the full dataset, analysed level 1 scans using the BSE template. No studies were excluded. Following unblinding, the echocardiographer compared level 1 with level 2 results.Results: Clinical characteristics of the pilot sample were similar to the broader cohort . Clinical questions were predominantly to exclude: impaired left ventricular function in patients with breathlessness 15(48%), significant valve disease in patients with a murmur 10(32%), and structural heart disease in patients with new arrhythmia 3(10%). Level 1 dataset was diagnostic in 30(97%). Level 1 scan was deemed sufficient in 21(68%) with progression to level 2 recommended in 10(32%). Of these 10, 7 were >70y with clinically significant valve disease. No clinically significant findings were missed when a level 1 scan was deemed sufficient.Conclusion: Our data suggest that, to exclude LV impairment as a cause of breathlessness, a level 1 dataset interpreted by an experienced sonographer is sufficient to answer the GP’s clinical question. This approach may offer more prudent healthcare but must be confirmed in larger, prospective studies. The high prevalence of valve disease in older patients with murmurs makes this population unsuitable for level 1 scans.Echo Research & Practice 2023, 10 (Suppl 1):ABS014Background: Echocardiography is an imaging modality that provides invaluable information in the diagnosis and treatment of disease. That said, it is a finite resource, with many healthcare services experiencing significant difficulties in service provision.Aims: To determine the patient factors that are associated with poor quality or non-diagnostic echocardiography studies.Methods: For all patients undergoing an echocardiogram between 2008 and 2021 at a large university teaching hospital, baseline clinical characteristics were extracted from the sonographer’s clinical report. Each variable was dichotomised and entered into a logistic regression model to determine those predictive of ‘very poor’ or ‘non-diagnostic’ images.Results: 180,693 patients who underwent echocardiography between 2008 and 2021 were enrolled into the CIRI Registry (Table 1). Image quality was poor in 34.8% of all studies . Four factors were predictive of poor image quality: obesity , inpatient scans , tachyarrhythmias , and male sex  . We developed a mosaic plot to combine these four variables to highlight the probability of poor imaging quality , with probabilities varying from 23 to 69%.Conclusion: Careful consideration of basic clinical characteristics can help determine which patients are likely to have non-diagnostic scans. This may help strained clinical services improve their diagnostic yield and develop routes to other imaging modalities in cases where echocardiography may not prove helpful. We propose a model that can be used to vet echocardiography requests to help provide a more sustainable service.Echo Research & Practice 2023, 10 (Suppl 1):ABS015Background: Recent publication of international cardio-oncology imaging guidance and the development of advanced analysis software has brought about a change in the routine monitoring of LV ejection fraction (LVEF) in echocardiography. Recommendations highlight 2D and 3D-LVEF and 2D-GLS as surveillance parameters of left ventricular systolic function for patients at risk of chemotherapy-related cardiac dysfunction (CTRCD).Aims: We sought to determine the feasibility of the acquisition and analysis of 3D-LVEF datasets compared to 2D- GLS and 2D-LVEF within a newly developed CO service.Methods: This was a single-centre retrospective analysis with minimal exclusion criteria (diagnosis of carcinoid heart disease). New patients  were referred to an NHS CO-TTE clinic. Using dedicated software , we sought to acquire and analyse 2D and 3D-LVEF and 2D-GLS adhering to the BSE CO-TTE protocol.Results: 3D-LVEF, 2D-GLS and 2D-LVEF was achievable  with no quantitative TTE imaging possible for poor TTE subjects (n = 19). There was a strong correlation between 3D LVEF and 2D LVEF . Acceptable correlation was also found between 2D-GLS with 2D LVEF and 3D-LVEF  . Most persistent obstacle to 3D-LVEF was poor endocardial border tracking (n = 26).Conclusion: Although 3D-LVEF was found to be reliable when obtainable, acquisition and analysis was only possible in 40% of the CO-TTE cohort. Conversely, 2D-GLS has been found to be achievable, reliable and comparable to established methods of LVEF assessment in TTE, even in this difficult patient population for adequate echocardiographic windows. We are confident with more experience of 3D analysis software, feasibility of acquisition and analysis will improve.Echo Research & Practice 2023, 10 (Suppl 1):ABS016Background: There is evidence that with relatively brief training, point-of-care ultrasound (POCUS) by nurses is feasible and increases the diagnostic yield of the examination. The literature is dominated by accuracy studies that do not explore repeatability or implementation challenges. Despite increasing government pressure to improve diagnostic testing out-of-hospital, prior studies have focused on use by specialist nurses within hospital settings. Since non-specialist community nurses often provide initial point-of-care assessments in elderly patients at home, we sought  to assess whether they could learn to detect global left ventricular systolic dysfunction (LVSD) and venous congestion accurately and reliably on ultrasound before considering potential clinical implementation.Methods: Four ultrasound-novice community nurses completed a bespoke POCUS training programme comprising of a 5-day introductory course and subsequent practice period. Nurses individually analysed fourteen pre-selected focused video cases (with/without pathology) blind to clinical information. Analyses were made using a strict protocol based on qualitative assessments of specified pathology. Repeat analysis occurred two-weeks later.Results: The nurses accurately (sensitivity 0.94 and specificity 0.89) and reliably detected LVSD with substantial intra-operator agreement (k =  ≥ 0.71). Abnormal IVC, pleural effusion, and B-line positivity were also detected accurately (sensitivity ≥ 0.85 and specificity ≥ 0.86) and reliably (intra-operator agreement k =  ≥ 0.71).Conclusion: After dedicated training, community nurses can accurately and reliably detect LVSD and signs of venous congestion on ultrasound. Nurse-led POCUS could potentially revolutionise diagnostic community care but the complexities of implementing POCUS within this setting are unknown. Therefore, a thorough evaluation of accuracy, reliability, and clinical impact is required. We are amidst studies in this area.Echo Research & Practice 2023, 10 (Suppl 1):ABS017Background: International echocardiographic guidelines for the assessment of pulmonary hypertension (PH) support a probability based approach for the presence of PH. Novel echocardiographic markers of right heart function such as strain are not included in current guidelines. These novel markers may help to detect PH.Aims: To investigate the feasibility of RA reservoir strain (RArS) assessment to detect PH in patients referred for assessment to a UK shared care PH centre.Methods: We retrospectively evaluated 324 patients referred for PH assessment. All patients had an echocardiogram and right heart catheter (RHC) . PH was defined at RHC . RArS was measured from the apical 4ch view. Echocardiographic measurements were made blinded to RHC data.Results: RArS was measurable on 258 patients (85%) (mean strain 23.6 ± 9.7%). Those with PH had significantly lower mean RArS compared to patients with no PH (22.2 ± 9.6 vs. 27.3 ± 8.3) p < 0.001. Subgroup analysis demonstrated that post capillary PH RArS (18.6 ± 8.9) was significantly lower than pre capillary PH RArS (23.1 ± 9.8%) (p = 0.01). Pre capillary PH was lower than no PH . Comparing RArS in groups using the BSE recommended echo probability grading, Low vs High probability demonstrated a significant difference (25.7 ± 9.6 vs. 21.5 ± 9.4%) (p =  < 0.01). ROC analysis showed good sensitivity (80%) but poor specificity (50%) for cut off RArS of Conclusion(s): RArS is feasible within this real-world cohort referred for PH assessment with good sensitivity. Further studies using RArS as part of a diagnostic algorithm with other markers will help to see if accuracy for detection of PH can be improved when compared with existing guidelines.Echo Research & Practice 2023, 10 (Suppl 1):ABS018Background: Pulmonary hypertension (PH) secondary to left heart disease (PH-LHD) remains the most common cause of PH. Echocardiographic assessment of PH to identify those with PH-LHD is important so that prompt treatment can be started and also to try to prevent unnecessary additional tests (e.g. right heart catheterisation (RHC)). Current probability algorithms do not include specific indices for assessment of left heart disease. Novel parameters such as Left Atrial Reservoir Strain (LArS) (%) have been shown to be of benefit when assessing left heart disease.To assess the feasibility of LArS measurement in identifying those with PH-LHDTo identify diastolic parameters in a real-world cohort able to differentiate between precapillary PH and PH-LHD.Methods: This was a retrospective evaluation of 324 patients referred for assessment of PH. All patients had an echocardiogram and RHC . The presence of PH was defined at RHC. Diastolic parameters were calculated, and LArS was measured using a dedicated atrial strain algorithm. All echocardiographic measurements were made blinded to RHC data.Results: LArS was achievable in 72% of the cohort. Precapillary, post capillary and no PH groups were arranged according to RHC data (*Table*1.0). Of all diastolic parameters, E/e’; indexed LA volume, Avg S’ and LArS were significantly worse in those with PH-LHD compared to both precapillary PH and those without PH. ROC analysis for these parameters showed acceptable ROC-AUC at 0.7–0.8, although no single parameter had both good sensitivity and specificity.Conclusion: LArS, in addition to E/e’, Avg S’ and indexed LA volume are able to differentiate PH-LHD from precapillary PH. LArS is feasible in this real-world cohort referred for evaluation of PH. No single diastolic marker has both good sensitivity and specificity for the detection of PH-LAD. Further work is needed to identify the optimal echocardiographic algorithm of diastolic markers to help identify PH-LHD. This could include more novel markers such as LArS and may be of additional benefit to current guidelines to help guide clinicians as to the potential presence of PH-LHDEcho Research & Practice 2023, 10 (Suppl 1):ABS019Aims: To assess the benefit of using the modified Duke’s criteria on echocardiography referrals for infective endocarditis.Phase-146 IE TTE referrals from September–November 2019 were retrospectively analysed. Blood culture (BC) results and case-notes were reviewed for major and minor criteria to calculate a Duke’s score (Rejected/Possible/Definite). Further transesophageal echocardiography (TOE) results were reviewed.Phase-2114 referred for assessment of IE underwent TOE from Oct 2017-November 2019. A Duke’s score was calculated and the initial TTE referral reviewed.Results: Of all of the TTE referrals made for suspicion of endocarditis, one Duke’s score was submitted as part of the referral.Phase-1Of the cohort, 35% (n = 16) were female (Avg-67yo) and 65% (n = 30) male (Avg-70yo). From calculation of Duke’s score: 48% rejected (n = 22), 30% possible (n = 14) and 22% definite (n = 10). 33% (n = 15) went on to have a TOE. No TOE evidence of IE found in subjects fulfilling rejected criteria. TOE results with evidence of endocarditis or unable to rule out IE (UTRO) 20% (1/5) had possible and 88% (7/8) definite .Phase-2Of the cohort, 35% (n = 40) were female (Avg-65yo) and 65% (n = 74) were male (Avg-66yo). Calculation of Duke’s score: 32% (n = 37) rejected, 52% (n = 59) possible and 16% (n = 18) definite. Of those with TOE with evidence of / UTRO IE: 14% (n = 5) rejected, 37% (n = 22) possible and 81% (n = 13) definite .Conclusion: Calculating Duke’s score for endocarditis referrals as recommended in recently published BSE triage criteria is useful for risk stratifying patients. This should be included in TTE referrals for the assessment of IE.Echo Research & Practice 2023, 10 (Suppl 1):ABS020Background: Increasing patient admissions, staff shortages and increased reliance on diagnostic tests have increased the waiting time for an inpatient transthoracic echocardiogram.Aims: The purpose of the study is to ensure the service can provide diagnostic echo provision to appropriate patients within an acceptable timescale.Methods: All inpatient echo referrals were retrospectively analysed at two time points: (a) November 2020–December 2020 and (b) July 2021 and August 2021. Referrals were identified from an electronic referral system and all inpatient referrals were included. Priority status indicated by referrer, date/time of referral, date/time of scan and referral indication were recorded for all referrals. Average time from referral to scan was analysed for both routine and urgent referrals. In July 2021 a triaging system was implemented utilising the 2021 British Society of Echocardiography triaging (BSE) guidelines to assess whether this improved service provision by reducing inappropriate inpatient referrals and therefore reduce inpatient waiting time.Results: There were a total of 435 inpatient referrals in 2020 (a) and there was an average waiting time for a routine referral of 10 days. Urgent referrals were seen within 5 days.In 2021 (b) there were 383 referrals for inpatient echocardiography. Average waiting time for routine referral was 52 h. All referrals for suspected endocarditis were scanned within the target timeframe of 48 h. Of all referrals 60% were prioritised as urgent by the requesting doctor. Only 10% were triaged as urgent by BSE guidelines.Conclusion: Implementing the BSE 2021 triaging guidelines has a positive impact on inpatient transthoracic echo provision, reducing the number of inappropriate referrals and improving the waiting time for all referrals. Prioritisation is standardised for all referrals and therefore the right patients are getting the right tests, quicker.Echo Research & Practice 2023, 10 (Suppl 1):ABS021Background: Contemporary evidence suggests clinically significant (moderate/severe) Valvular Heart Disease (VHD) affects 13.3% in people ≥ 75yrs but this data comes from rural, suburban regions with a predominant Caucasian population. We have a paucity of data of disease incidence within urban, inner city communities such as North East London (NEL), with a high migrant population, greater cardiovascular risk profile and more rheumatic heart disease. We therefore performed community based hand-held focussed echocardiography on people ≥ 65yrs old in NEL to detect left-sided VHD and left ventricular systolic dysfunction (LVSD).Methods: 518 patients without known VHD or LVSD ≥ 65yrs old were scanned across 4 GP practices and 1 vaccination centre, using handheld ultrasound. An abbreviated dataset incorporating colour flow and 3/6 standard echocardiography views were used. All studies were uploaded via a secure network and read by an independent expert for verification.Results: Of the 518 patients, ethnic origin was Asian 74%, White 14.4%, African 9.9% and Other 1.3%.Newly diagnosed VHD or LVSD was found in 37% of patients. 16(6.4%) had mild LVSD, 6 (2.4%) had moderate LVSD and 2 (0.8%) had severe LVSD. Mild VHD was most common with mitral regurgitation (MR) being the most common valvular pathology (59%). Aortic Regurgitation (AR) was found in 23%, aortic stenosis (AS) in 15% and mitral stenosis (MS) in 3.5%.Conclusion: The prevalence of VHD and LVSD within NEL is greater than contemporary estimates, possibly due to racial and socioeconomic factors. Handheld ultrasound is a useful tool for community detection of VHD and LVSD.Echo Research & Practice 2023, 10 (Suppl 1):ABS022Background: Most of our population statistics on Valvular Heart Disease (VHD) come from rural or suburban western communities. In high migrant populations such as North East London (NEL), the burden of disease may be different relating to genetic factors, comorbidities and deprivation. Redbridge, a unique borough in NEL contains 20% of neighbourhoods amongst the most deprived in the nation and 20% of the least deprived.We do not understand the valve disease burden in such a cohort. Planned intervention and early detection could remove 25% of valve-related heart failure hospitalisations.Methods: 518 patients ≥ 65yrs old were screened for VHD using handheld echocardiography. Patients were recruited from 4 GP practices– 2 practices in a suburban sector of NEL (lower deprivation) and 2 in a more urban area (higher deprivation).Results: The highest prevalence of VHD (44%) occurred in 1/2 of suburban GP practices, whilst the lowest (33%) occurred in the urban GP practice with the highest deprivation. The second suburban GP practice had a prevalence of 39%, whilst the remaining urban GP had 40%.The mean age and proportion of female patients in the 2 practices with the highest deprivation was 74.1yrs and 49.7% compared to 72.2yrs and 55.7%. The prevalence of valve disease in the 2 practices with the highest deprivation was 36.5% compared to 41.7% . The proportion of moderate/severe valve disease in the 2 practices with the highest deprivation was 22.5% compared to 25.9%.Conclusion: There is a significant difference in prevalence of VHD within GP practices as little as 2 miles apart. The proportion of moderate/severe VHD is much higher than contemporary estimates but the deprivation of the area is not the explanatory factor. It is more likely that other factors especially age, ethnicity and gender explain the variance.Echo Research & Practice 2023, 10 (Suppl 1):ABS024Aim: To audit echocardiography requests in patients with heart failure (HF) and stroke using BSE triage guidelines as a gold standard.Phase 1 (audit): Retrospective review of 169 echocardiography requests in stroke patients (Jan-Dec 2021) and 40 requests in HF patients (Jan-Feb 2021). New BSE triage guidelines was used as the gold standard.Phase 2 (intervention): Subsequent findings were presented at the medical grand round. BSE triage guidelines were implemented and disseminated Trust wide.Phase 3 (re-audit): Reaudit performed over 4 weeks following implementation of BSE triage guidelines.Methods:Results: Initially, 75% of stroke requests and 50% of HF requests were non-compliant with BSE triage guidelines and contained insufficient clinical information for adequate triage. Reaudit post intervention demonstrated that now 77% of referrals for stoke / HF contained sufficient information for appropriate triage. 23% of referrals were removed from the waiting list as not indicated as an inpatient.Comparison of a 4 week period between the 2 data subsets showed that implementation of the triaging system led to 20 fewer echocardiograms being performed. Extrapolating this over 1 year would lead to a 12% reduction in inpatient echocardiography.Conclusion: Implementation of BSE triage has helped to standardise the clinical information submitted on echocardiography referrals for stroke and HF. Implementation of BSE triage guidelines in our department has been shown to improve the workload within an overstretched inpatient service.Echo Research & Practice 2023, 10 (Suppl 1):ABS014Background: Left ventricular ejection fraction (LVEF) is an important marker of systolic function assessed by transthoracic echocardiography (TTE), often predicating clinical decision making. The multiple methods to assess LVEF using TTE may yield variable results.Aim: Assess image acquisition and LVEF reporting against British Society of Echocardiography (BSE) guidelines, comparing various methods of assessment.Methods: Retrospective assessment of consecutive TTE studies / reports for image quality, documentation of challenging studies, LVEF (percentage & grade) and method(s) to quantify. Multi-modality imaging comparisons were performed in patients with cardiac magnetic resonance (CMR) within 6 months of TTE.Results: 467 patients  were included. 150 studies (32%) reported poor endocardial definition, with a median of 5 LV segments poorly visualised. The most common method of TTE LVEF assessment was visual estimate (83%) followed by Simpson’s biplane 15%). In patients with < 2 segments poorly- visualised, LVEF assessment was performed using visual estimate in 77% and Simpson’s biplane in 23%. In patients with ≥ 2 segments poorly visualised LVEF assessment was performed using visual estimate in 90% and Simpson’s biplane in 10%.63 patients had contemporaneous TTE + CMR with quoted LVEF %, with a median difference of 2.5% . A highly significant positive correlation between the modalities was seen for both visual estimation and Simpson’s biplane method. 66 patients with TTE + CMR had graded LVEF for comparison, with 6 being discordant > 1 grade.Conclusion: There is underuse of Simpson’s Biplane method regardless of number of poorly visualised segments. TTE showed good correlation with CMR irrespective of method of assessment . However, TTE misclassified a proportion of patients. Routine utilisation of techniques to improve accuracy including contrast enhancing agents for poor endocardial definition and automated quantitative LVEF assessment are needed.Apostolos Tsiachristas and Paul Leeson are joint senior authorsEcho Res Pract 10, 8 (2023). https://doi.org/10.1186/s44156-023-00020-1Echo Research & Practice 2023, 10 (Suppl 1):ABS014Echo Research & Practice 2023, 10 (Suppl 1):ABS027Background: Left ventricular (LV) global longitudinal strain (GLS) is considered a sensitive and prognostic marker in assessing ventricular systolic function in a range of diseases. Its clinical utility requires operator experience, analysis time and good image quality, and it is subject to intra- and inter-observer variability. The emergence of artificial intelligence (AI)-based analysis may offer a valuable clinical solution in measuring GLS.Aims: This evaluation assesses whether AI–automated analysis has utility in assessing LV-GLS in trastuzumab-treated patients compared to manual analysis.Methods: In this retrospective audit, AI-automated (Ultromic EchoGo Core) and manual (Philips QLab) measurements of GLS and LV ejection fraction (LVEF) were obtained from standard apical views in 569 transthoracic echocardiographic studies from 128 patients receiving trastuzumab.Results: AI-automated analysis yielded GLS and LVEF data less frequently (12%) than conventional analysis . AI-automated longitudinal strain analysis in each of the apical 4-, 2-, and 3-chamber views was feasible in 51%, 47%, and 12%, respectively, compared to manually analysis  . A fair correlation was shown between AI- and manually generated values, for both GLS  and LVEF  .Conclusion: AI-automated analysis represents a potentially valuable tool for the assessment of GLS and LVEF but was successful less frequently than manual assessment. Further work should explore whether: (1) AI-based analysis is superior to less experienced humans, (2) image rejection threshold appropriateness, and (3) accuracy of AI data vs manual data.Echo Research & Practice 2023, 10 (Suppl 1):ABS028Background: Echocardiographic imaging and quantification of segmental longitudinal strain (SLS) can provide important clinical information in patient management and risk stratification. However, high variability, poor reproducibility and the prerequisites for technical expertise limit clinical use and applicability. Automated quantification of SLS, driven by AI, has the potential to overcome these limitations and quantify myocardial function unbiased.Methods: Using EchoGo Core v2.0, we retrospectively analysed a publicly available dataset  of 161 apical 4 chamber transthoracic echocardiograms from patients admitted to Hamad Medical Corporation with acute ST-elevation myocardial infarction (MI) between 2018–2019. Infarcted segments were identified by full agreement between 3 cardiologists.T-tests were used to assess the differences in peak SLS between infarcted and non-infarcted segments. Prediction of infarct presence and severity using peak SLS is analyzed using receiver operator characteristics (ROC) curves. The correlation with mean peak SLS and total number of infarcts over all segments was assessed using ANOVA and subsequent t-test with Benjamini–Hochberg correction. ROC analysis was performed to assess prediction of infarct presence (0 vs 1–6 infarcts). Correlation between peak SLS in the 6 segments was, irrespective of infarct presence, assessed through paired Pearson correlation tests.Results: MI of individual segments was present in 93 patients. Infarcted segments were predominantly in the apical Inferoseptum and neighboring 2 segments. Mean peak SLS significantly increased with infarct presence in each individual segment. ROC curves stratifying infarct presence by peak SLS achieved area under the curve (AUC) values between 0.727 and 0.825. Mean peak SLS over all segments significantly increased with increasing number of infarcts (p < 0.001). ROC curves show an increase in prediction accuracy with increasing infarct severity, with AUC = 0.681 for 0 vs 1 infarcts, going to > 0.9 for 0 vs 3–6 segments. Peak SLS is significantly correlated between all segments (p < 0.001), with the strongest correlations between neighboring segments (R > 0.69).Conclusion: Unbiased assessment of infarct presence and severity is feasible with automated AI quantification of peak SLS. Regional systolic function was measured to deteriorate with both the presence and severity of infarcts and was strongly correlated with that of neighboring segments, indicating that the automated analysis was sensitive to concomitant dysfunction in non-infarcted segments.Echo Research & Practice 2023, 10 (Suppl 1):ABS029Introduction: There is growing evidence that global longitudinal stain (GLS) is an early predictor of left ventricular systolic dysfunction. However, it is not performed routinely in clinical practice in most echocardiography departments. Introducing new techniques into clinical practice can present challenges at the individual, departmental and societal level and understanding potential barriers is fundamental to facilitate successful implementation.Purpose: To identify potential barriers to the use of GLS in clinical practice in England.Methods: Online and anonymous questionnaire, adapted from determinant of behaviour questionnaire , to BSE physiologists/scientists within England to assess current practice and barriers prior to BSE cardio-oncology guidelines 2021. Demographic data, individual experience, departmental practice, opinions on GLS and determinants of behaviours were recorded using Likert scales and free text responses.Results: A total of 55 responses were received. A majority agreed that GLS can improve patient care (85.2%) however less than half are performing GLS regularly (48.1%). Emerging themes for barriers to use included: time for including GLS into appointment time, lack of training and suboptimal image quality.Training at individual, departmental and national level on performing GLSPlanned training clinics with time to perform GLS and for image optimisation for GLS calculations.The important use of GLS in cardio-oncology is highlighted in the 2021 BSE guidelines. The questionnaire identified key areas that need development plans to ensure GLS in incorporated into practice:Echo Research & Practice 2023, 10 (Suppl 1):ABS031Background: Until recently, little attention has been paid to whether the heart of the black athlete is universal, or whether substantial differences exist according to geographic origin. Whilst West African athletes have been shown to demonstrate more pronounced left ventricular remodelling than West Asian and East African counterparts, after accounting for body size. The relative impact of geographical origin upon the paediatric athletes’ heart remains unknown. We examined the impact of geographical origin upon left ventricular (LV) structural remodelling in the black paediatric athletes’ heart.Methods: 200  male paediatric (11–18 years) athletes, were evaluated by 2D echocardiography as per British Society of Echocardiography recommendations, with geographical region categorised by United Nations definitions . LV dilatation and hypertrophy were categorised by the Paediatric Heart Network Z-Scores.Results: Paediatric West African athletes presented significantly greater intraventricular septal wall thickness during diastole than East African and West Asian athletes, respectively (Table 2). East African athletes presented significantly smaller posterior wall thickness during diastole than West Asian and African athletes, respectively. Upon application of the Paediatric Heart Network Z-Scores to account for body size, statistical differences in the prevalence of hypertrophy did not differ by geographical origin.Conclusion: In contrast to findings in the adult male black athletes’ heart, differences in the prevalence of left ventricular hypertrophy were removed after accounting for BSA. Findings likely attributable to reduced years of training and incomplete pubertal development.Echo Research & Practice 2023, 10 (Suppl 1):ABS032Background: LVEF is used for assessment of cancer therapy-related cardiac dysfunction (CTRCD) in patients who receive cancer therapies. Cardiovascular Magnetic Resonance (CMR) is the reference standard for LVEF assessment, but echocardiography is most widely used. This study sought to compare LVEF measured by echocardiography and CMR in cancer patients with suspected cardiotoxicity and assess potential impact on clinical decision-making.Methods: In this prospective single-center observational study, 745 patients underwent same-day imaging with echocardiography and CMR. A sub-set of 74 patients also had 3D echocardiography-derived LVEF. Agreement of LVEF was determined by Bland–Altman analysis.Results: Mean age 60 ± 5 years, 62% female. LVEF measured by 2D echocardiography was significantly lower compared to CMR, (median 60% [interquartile range 54–65%]) vs 63% [interquartile range 56–69%], p < 0.001). Using Bland–Altman analysis, mean bias was -3.7 ± 7.6% (95% limits of agreement [LOA] -18.5 to 11.1%) of 2D echocardiography versus CMR derived LVEF . Among 74 patients in whom CMR, 3D echocardiography and 2D echocardiography were performed, LVEF was 60.0 ± 10.4%, 58.4 ± 9.4% and 57.2 ± 8.9%, respectively (p = 0.0006) . There was better agreement with 3D echocardiography and CMR derived LVEF (mean bias -1.6 ± 6.3 [95% LOA -13.9 to 10.7%]) compared to 2D echocardiography and CMR derived LVEF (mean bias of -2.8 ± 6.3 [95% LOA-15.2 to 9.6%]), (p = 0.02).Conclusion: 2D echocardiography and CMR derived LVEF measurements are not interchangeable. 2D echocardiography has variations of up to ± 15% compared to CMR. 3D echocardiography has better agreement with CMR derived LVEF. This study supports the use of 3D echocardiography in cardio-oncology patients and suspected CTRCD.Echo Research & Practice 2023, 10 (Suppl 1):ABS033Background: Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by muscle hypertrophy and fibrosis, interfering with force generation and relaxation. Abnormal ventricular (LV) myocardial deformation have been demonstrated in patients with HOCM at rest, but there is lack of data regarding the deformational mechanics in exercise.Aims: We wanted to assess the adaptability of LV deformational behaviour to physical exercise in HCM patients as compared to healthy control subjects.Methods: 24 obstructive HOCM  and 32 control subjects  underwent supine bicycle stress echocardiography (ESE) with measurements of 2D- and Doppler, 2D-Speckle Tracking Tracking Imaging and 3D-Full Volume Analysis. Conventional LV and RV functional measurements; longitudinal (LS), circumferential (CS) values; peak Twist and Torsion angles; post-systolic shortening index (PSS) and diastolic phase indices (Untwisting time—UTT and rate—UTR); LV/RV-EF by 3D-Full Volume Analysis was performed off-line by TomTec Arena™ software package both at rest and on submaximal ESE.Results: The HOCM group had lower resting LS  but higher CS  and Twist angles  than control subjects. Exercise induced an increase in all strains in control subjects, but much less in HOCM ; the increase of Twist angle was minimal in HOCM . The PSS was more pronounced on ESE in HOCM than in controls . Peak UTR was slower (118 ± 2.1 vs 133.1 ± 14.1 º/s) during ESE and occured later  in HOCM than in controls. There was significant relationship between Twist and UTR in control subjects , but not in HOCM .Conclusions: The HOCM patients had significantly impaired strain-adaptability; developed post-systolic shortening and no LV Torsional reserve was found on exercise. Decreased and delayed UTR indices were also detected, becoming more pronounced in the HOCM group. These findings support evidence for reduced systolic-diastolic coupling efficiency, assessed by Twist-Untwist mechanics in HOCM patients, which can contribute to the development of exercise-related symptoms and the dynamic LVOT-obstruction. This unique pattern of deformational behaviour to exercise can help in the differential diagnostic workup in patients with LV hypertrophy of unknown aetiology and also would hold additional value in the risk stratification process for patients with different cardiomyopathies.


Alterations in CV imaging parameters can lead to early recognition of various types of CVD. In this paper, we briefly discuss the role of noninvasive imaging modalities, emphasizing the benefits of including cardiovascular magnetic resonance (CMR) in the evaluation of DM. CMR, in the same examination, can provide an assessment of tissue characterization, perfusion and function, with excellent reproducibility and without radiation or limitations, due to the body habitus. Therefore, it can play a dominant role in the prevention and risk stratification of DM. The suggested protocol for DM evaluation should include routine annual echocardiographic evaluation of all DM patients and CMR assessment of those with poorly controlled DM, microalbuminuria, heart failure, arrhythmia and recent alterations in clinical or echocardiographic evaluation.Diabetes mellitus (DM) is a new epidemic which has presented an immense increase in recent decades, due to the rapid increase in obesity. Cardiovascular disease (CVD) significantly reduces life expectancy and is the main cause of death in type 2 diabetes mellitus (T2DM). Strict glycemic control is a well-established method to combat microvascular CVD of type 1 diabetes mellitus (T1DM); its role against CVD of the T2DM risk has not been well documented. Therefore, the most efficient prevention is multifactorial risk factor reduction. Recently, the European Society of Cardiology published its 2019 recommendations on CVD in DM. Although all clinical points were discussed in this document, only a few comments were presented about when and how we should recommend cardiovascular (CV) imaging. Currently, CV imaging is the  Diabetes mellitus (DM) is a new epidemic which has presented an immense increase in recent decades due to the exponential increase in obesity. According to the International Diabetes Federation (IDF), about 415 million people worldwide have DM, of whom 91% have type 2 diabetes mellitus (T2DM) [Cardiovascular disease (CVD) is the main cause of death in patients with T2DM, especially in low-/middle-income countries. Universally, CVD affects about 32.2% of all patients with T2DM and represents a significant cause of mortality, as it accounts for approximately 50% of all deaths over the period 2007–2017, with stroke and coronary artery disease (CAD) being the main causes . FurtherThe high clinical impact of CVD in patients with T2DM underlines the importance of the joint management of CVD and T2DM, with strict glycemic control remaining the main focus of treatment. The role of strict glycemic control against CVD and microvascular complications has been well documented in T1DM ,7; howev“must” in clinical CV evaluation. Alterations in CV imaging parameters may lead to early identification of various types of CVD. Furthermore, CV imaging provides direct information regarding the status of both nyocardium and coronary arteries that cannot be reached by blood biomarkers. The main CV imaging modalities currently used in the evaluation of DM include.With this aim in mind, the European Society of Cardiology (ESC) recently published its 2019 recommendations on “what we have to do in diabetic patients” . AccordiEchocardiography represents the main imaging modality, used in the clinical practice of cardiology, because it is a cost-effective, widely available, bedside modality that lacks ionizing radiation. It provides reliable data on the function of both the atrium and ventricles of the heart and can reveal early diastolic dysfunction usually found in early DM . Two-dimThe most common echo finding in both symptomatic and asymptomatic DM patients is diastolic dysfunction. According to a recent publication, the aggravation of left ventricle (LV) diastolic function is more evident in DM patients than controls. Furthermore, the probability of LV diastolic dysfunction is higher with greater HbA1c and a longer duration of DM .Recently, speckle tracking echocardiography detected subtle myocardial alterations in DM patients before they develop symptoms and before conventional echocardiography detects any change. Global longitudinal strain (GLS), assessed by speckle tracking echocardiography (STE), was impaired in patients with DM, compared to controls . FurtherThe most commonly used nuclear technique for the evaluation of myocardial ischemia/fibrosis in patients with DM is single-photon emission computerized tomography (SPECT), which is widely available; there is extensive experience of its use. However, SPECT has important limitations including the use of radiation and low spatial resolution that precludes detection of subendocardial ischemia/fibrosis. Furthermore, SPECT, because it is based on regional differences of myocardial blood flow, is less accurate in the detection of balanced ischemia, diffuse microvascular disease and subendocardial infarction . A studyNuclear techniques can detect CFR changes, and similarly to echocardiography, both symptomatic and asymptomatic patients with T2DM and normal coronary arteries may exhibit reduced CFR compared to controls, when assessed via technetium sestamibi scanning .82Rb stress PET [In contrast to SPECT, positron emission tomography (PET) uses less radiation and can be of great value regarding the evaluation of myocardial ischemia in DM. Myocardial perfusion has allowed incremental risk prediction of cardiac death in large cohorts of patients with or without DM, referred for clinical ress PET . Howeverress PET .PET can more accurately quantify CFR and myocardial blood flow (MBF). PET has shown significant alterations in the MBF of asymptomatic patients with T2DM (vs. controls) during dipyridamole stress . There aCardiac computed tomography (CCT) allows non-invasive visualization of coronary arteries. Significant obstructive CAD is related to adverse cardiovascular outcomes, as in non-T2DM subjects. Regarding asymptomatic individuals, a meta-analysis of 10 studies pertaining to 5012 individuals with T2DM demonstrated that both non-obstructive and obstructive (≥50% stenosis) CAD were significantly associated with adverse events, as was the extent of CAD . PatientRecently, it has been shown that in DM patients with stable chest pain, a computed tomographic coronary angiography (CTCA) approach was associated with fewer adverse CV events than a functional stress-testing strategy and that, therefore, it could be an initial diagnostic tool for these patients . FurtherDM and PRE-DM are chronic diseases involving mainly the CV system and are considered as an equivalent to CAD. Therefore, there is a great clinical need to have a reliable diagnostic tool with good reproducibility, which can detect early myocardial alterations and can be applied repetitively without using radiation. CMR presents all these characteristics, because it has the best spatial resolution allowing it to detect small myocardial changes, missed by other imaging modalities. Additionally, CMR is the only modality that can evaluate cardiac function, stress-rest perfusion and perform tissue characterization .(i) Evaluation of Cardiac FunctionCMR uses different types of images (sequences) to answer various questions regarding tissue characterization, perfusion and function in DM patients. The most common sequences in clinical practice include:The CMR pulse sequence for functional evaluation is called balanced steady-state free precession (bSSFP) and represents the gold standard for the assessment of cardiac mass, wall motion, anatomy, as well as atrial and atrial/ventricular function .(ii) Evaluation of Myocardial Perfusion with Stress CMRRapid cardiac imaging with the use of T1-W after pharmacologic hyperaemic stress with adenosine  and injection (bolus) of paramagnetic Gd-based contrast agent can provide accurate and reproducible data regarding myocardial perfusion during stress . This teStress CMR imaging has no limitations depending on the body habitus, and is the method of choice for epicardial and micro-vascular CAD, especially for individuals who cannot exercise adequately or completely . The CE-(iii) Tissue Characterization(a) T1-weighted (T1-W) Images and Late Gadolinium Enhancement (LGE)This can be achieved using different types of images that reflect different cellular properties of myocardium. These images include:T1-W imaging is the ideal sequence for CMR morphological assessment. Late gadolinium enhanced T1-W images (LGE), taken with the use of inversion recovery pulse sequences 10–15 min post gadolinium-based contrast administrations, represent the gold standard for the assessment and quantification of myocardial replacement fibrosis (scar) . LGE canThe typical CMR image of myocardial infarction, commonly found in DM and PRE-DM, includes transmural or subendocardial LGE following the epicardial coronary arteries’ distribution. Subepicardial, patchy or intramyocardial LGE, usually in the inferolateral wall, is related to myocarditis, irrespective of etiology . Furthermore, diffuse subendocardial LGE not following the typical distribution of coronary arteries’ territories is often related to microvascular coronary artery disease, as in DM with normal epicardial coronary arteries. (b) T1 Mapping and Extracellular Volume Fraction (ECV)LGE is the method of choice for detection and quantification of replacement fibrosis; however, it has inherent limitations to evaluate diffuse myocardial fibrosis, because it uses signal intensity differences between normal and scarred myocardium . ParametECV is more reproducible than native and post-contrast T1 at different field strengths, acquisition methods and vendors, therefore showing better agreement with histology .Native T1 mapping can increase in the remote myocardial infarction area, representing bad prognosis. Moreover, increased values of native T1 mapping and ECV can be early signs of various cardiomyopathies, before the detection of strain and strain rate abnormalities . Further(c) T2-weighted (T2-W) ImagesT2-W images are the outcome of water accumulation, due to myocardial oedema , and ref(d) T2 mappingHas been proposed as a more reliable alternative to classic STIRT2 images. To overcome the problems of STIR T2, a parametric image of each voxel is reconstructed in T2 mapping. Although T2 measures are reproducible and independent of the heart rate and body habitus, they can vary with different field strengths or scanner types .(e) T2* mappingIs the most reliable index of the assessment of iron deposition and evaluation of chelation treatment in patients with iron overload, due to multiple blood transfusions as in thalassemia or myelodysplastic syndromes. Furthermore, it is an excellent index for assessing iron overload in patients with genetic iron metabolism disorders, such as hemochromatosis. However, more details on this topic are beyond the scope of this review .(iv) Magnetic Resonance AngiographyMagnetic resonance angiography (MRA) is considered as accurate as X-ray angiography in the detection of great vessel anomalies, and an important tool for patients with DM . Non-con(v) LV DeformationClinically, a LVEF is commonly used to assess cardiac function. It should be noted that in the early stages of heart disease, a LVEF may be preserved despite alterations in the myocardial contractility. LV deformation expressed as a myocardial strain is a useful tool to evaluate the subclinical LV alterations. Myocardial strain can be measured by echocardiography, CMR tissue tracking and MR tagging. Echocardiography is frequently used for strain analysis, but its accuracy is dependent on operator training and patient body habitus. CMR tagging requires special sequences, whereas the post-processing assessment is time-consuming and complex. Lastly, CMR tissue tracking is considered a quantitative technique allowing fast analysis of the myocardial strain .CMR tissue tracking can evaluate the motion of myocardial voxel and provide important data concerning myocardial strain in subclinical myocardial abnormalities before myocardial injury leads to significant decrease in the LVEF. SSFP cine sequences are appropriate for CMR tissue tracking, which, using a rapid post-processing system, may provide ideal evaluation of LV myocardial strain. In a recent study evaluating patients with T2DM, circumferential PS and global radial peak strain (PS) did not differ significantly between patients with a preserved LVEF and controls. Nevertheless, longitudinal PS was significantly lower in patients with a preserved LVEF than controls, suggesting an independent association of global longitudinal PS with the LV remodeling index .(vi) Magnetic Resonance Spectroscopy (MRS)1H), can detect increased myocardial triglyceride content in patients with T2DM, which reflects cardiac steatosis that can also be present in subjects with a preserved LVEF [31P (phosphorus) MRS [31P MRS represents a non-invasive index of myocardial energetics. This is diminished in patients with T2DM and correlates with coronary microvascular dysfunction, reduced myocardial oxygenation/perfusion, and diastolic or subclinical systolic dysfunction [Magnetic resonance spectroscopy (MRS), with the use of proton (ved LVEF . Steatosrus) MRS . Lastly,function .Although the expertise and availability of CMR are generally low, today there is an increase in CMR in clinical practice.CMR is contraindicated in patients with non-MRI conditional devices or metallic clips .Caution is needed for the use of gadolinium-based contrast agents (CA) in patients with renal impairment (GFR < 30 mL/min) . It shouUsing CMR in the decision-making process has a clear benefit evident in a cost-minimization analysis for cardiac revascularization of these patients .Recently, ESC published guidelines regarding the management of CVD in DM . The recFurthermore, in the assessment of CAD in patients with DM, the distinction between T1DM and T2DM regarding the pathophysiology of CAD should be taken into serious consideration. It is well documented that microvascular coronary artery disease (M-CAD) is the main type of CAD found in T1DM, while epicardial coronary artery disease (E-CAD) is more common in T2DM . In thisRoutine baseline echocardiographic evaluation on an annual basis in parallel with evaluation of microalbuminuria, glycemic status and lipid profile of all DM patients.Evaluation of silent or overt perfusion/fibrosis lesions. In this context, CMR is preferable to other imaging modalities as having the best reproducibility and providing all the necessary information, missed by other imaging modalities, without using ionizing radiation. Furthermore, the CMR detection of silent CVD may seriously impact the DM patient treatment motivating the early use of ACE-inhibitors, b-blockers, ranolazine and other cardioprotective medications.Cardiovascular magnetic resonance (CMR) and positron emission tomography (PET), on the other hand, represent the ideal imaging methods for the assessment of M-CAD . HoweverDiabetes mellitus (DM) is the new epidemic of our time, presenting a rapid increase worldwide. The recently published ESC guidelines focus on the accurate assessment of themetabolic profile and modification of CVD risk factors. However, CV imaging should be considered as a useful adjunct in the clinical evaluation of all patients with DM or PRE-DM.Echocardiography should be recommended as the routine primary cardiac evaluation together with all required blood tests on the basis of annual evaluation for CAD. Stress echocardiography and SPECT, although they are the routinely used methods for fibrosis/ischemia assessment, both carry various limitations, such as acoustic window dependency and low spatial resolution, respectively. Furthermore, SPECT uses radiation, which does not allow its routine application on an annual basis. Therefore, for the evaluation of myocardial fibrosis/ischemia in DM, CMR seems clearly superior to all other imaging tools, as it is non-invasive without radiation and with high spatial resolution and excellent reproducibility that can detect small infarcts missed by other imaging modalities, can reliably differentiate M-CAD from E-CAD and guide further risk stratification/treatment evaluation of these patients.


No deaths or coronary compression occurred during the procedure. Over a 1-year follow-up, no stent displacement or fracture occurred. Only two patients had trace paravalvular leaks. Magnetic resonance imaging revealed a reversal of right ventricular remodeling, with a significant reduction in right ventricular end-diastolic volume index (p < 0.001) and improved right ventricular ejection fraction (p < 0.001). All patients achieved primary endpoints. Conclusion: 3D printing-guided PT-Valve implantation in enlarged nRVOT for severe PR is safe and effective, expanding TPVR indications and offering potential treatment for a broader patient population.Background: Severe pulmonary regurgitation (PR) often occurs following a transannular patch repair of tetralogy of Fallot, resulting in an enlarged native right ventricular outflow tract (nRVOT) with varying shapes. Methods: We conducted a single-center study with eight patients having severe PR and enlarged nRVOT (diameters ≥ 29 mm). Transcatheter pulmonary valve replacement (TPVR) was performed using the self-expanding PT-Valve. Preoperative evaluation included echocardiography, computed tomography, and magnetic resonance imaging. A 3D-printed model of the nRVOT was used for preoperative assessment. Follow-up data were collected in 1-year follow-up. Results: PT-Valve was successfully implanted in all patients, resulting in immediate improvement of severe PR. Pulmonary artery diastolic pressure increased significantly ( Severe pulmonary regurgitation (PR) is the commonly encountered lesion following repair of pediatric and adult tetralogy of Fallot (TOF), and the patients eventually end up with right ventricular dilation and dysfunction, arrhythmia, and limited exercise capacity ,2,3. Trap-valve , has demonstrated promising outcomes  were enrolled in this study. The inclusion criteria were as follows: (1) patients who were at least 10 years old or weighed more than 25 kg; (2) PR fraction ≥ 30% confirmed by cardiac magnetic resonance imaging (MRI) or a severity grade of PR ≥ 3+ measured by transthoracic echocardiography; (3) New York Heart Association (NYHA) functional class ≥ II or = I; and concomitant right ventricular end-diastolic volume index (RVEDVI) ≥150 mL/mGated cardiac computed tomography and MRI were utilized to assess the anatomical structures and determine the potential for coronary artery compression. Invasive right heart catheterization was used to evaluate the hemodynamics of the right ventricle (RV) and the PA. Additionally, both transthoracic echocardiography and transesophageal echocardiography (TEE) were conducted on all patients prior to the procedures to assess the function of the pulmonary valve and the RVOT.The PT-Valve  is a pericardial tissue valve derived from porcine sources. It is mounted on a self-expanding nitinol frame that is covered by porcine pericardium. The valve frame is available in five different sizes to accommodate the various morphologies of nRVOT. The nitinol frame is laser-cut and designed with a symmetrical shape to ensure stability and a tight seal on both sides of the RV–PA conduit. The outflow and inflow diameters of the valve frame are equal and come in sizes of 28, 32, 36, 40, and 44 mm, respectively. The length of the frame ranges from 38 to 54 mm, and the porcine valve itself has diameters of 20, 23, and 26 mm in the middle of the frame. It is intentionally smaller than the outflow and inflow diameters of the frame to avoid compression. To mitigate leaflet calcification, the tissue prosthetic is pretreated with specific “alcohol” and “surfactant” .The delivery system (21F) comprises an outer sheath that compresses the stent, an attachment system featuring three recessed areas for the placement of corresponding stent extenders, and a short-tapered nose cone to aid in smooth delivery. Additionally, a loading attachment has been developed to assist in folding the stent within the outer sheath. To ensure accurate positioning, a manually controlled release system allows for a gradual withdrawal of the outer sheath, starting from the distal frame and controlling stent expansion during device delivery.The patients’ computed tomography angiography (CTA) data were imported into Materialize Mimics 21.0 version software . Three orthogonal sections  were established using the multiplane interactive reconstructed imaging function of the software based on actual needs. Then, the initial digital 3D model of the RV–PA conduit and the adjacent tissues reconstruction were reconstructed by repeated comparisons and confirmations, and the collected data were converted to the standard format of Digital Imaging and Communication of Medicine for storage. The comprehensive reconstruction of the RV–PA and the distal PA morphology was performed using Materialise 3-matic software . In addition, different parts of the digital 3D reconstructed model were exported into the Standard Tessellation Language format, and the resulting files were imported into the Polyjet 850 multi-material full-color 3D printer  for printing to produce the patient-specific 3D model . We chosThe guidewire was carefully inserted through the PA branch of the 3D-printed model, eventually exiting the RVOT. With the guidance of the guidewire, the delivery system was successfully maneuvered into the RV–PA conduit. Taking into account the complex shapes and sizes of the conduit, the appropriate distal landing zone for the stent was selected. Following the release of the stent, close attention was given to assessing the anchoring planes at both ends of the stent and ensuring its stability. This evaluation was crucial in determining the risk of a paravalvular leak (PVL) and potential stent compression. By carefully monitoring these factors, any concerns or issues could be promptly identified and addressed to ensure optimal performance and functionality of the implanted device .All procedures were performed with the patient under general anesthesia. The right femoral vein was punctured for implantation of the delivery system (21 F). Then, the angiographic catheter was inserted via the left femoral vein into the RV to present the position and geometry of the RV–PA and to guide precise implantation of the bioprosthesis. Given the dumbbell shape, the slender waist of the frame design, and the preprocedural 3D reconstruction and 3D printing guidance, a coronary artery compression test was not performed before the bioprosthesis was implanted. The delivery system was introduced to the RV–PA after a Double Curve Lunderquist guidewire  was placed in the distal PA. Then, the appropriately sized stent was deployed in the selected landing zone according to the evaluation and simulation of preprocedural 3D printing guidance. After performing angiography to rule out PVL and PR and confirming excellent hemodynamics using TEE, the delivery system was withdrawn and removed, and the femoral venous puncture points were closed surgically with sutures .Baseline data were collected from the electronic medical record system. The operating time and the fluoroscopy time were recorded. In addition, data were collected during the hospitalization period .max) ≤ 35 mmHg], without the need for device removal within 24 h of implantation. The secondary goals of the study were to observe if there were any cardiovascular-related deaths, implant displacements, valve failures, or other major adverse events associated with the device. These adverse events included valve embolism, stent fracture, structural deterioration (excluding stent fracture), PVL, thrombosis, pulmonary embolism, endocarditis, and hemolysis.The data were collected from enrolled patients at various time points: at baseline, before discharge, and at 30 days, 6 months, and 1 year after the operation. The primary endpoints of the study were to achieve a successful operation and to implant the device successfully. A successful valve implant was defined as follows: The valve was placed securely in the desired position, and the bioprosthesis functioned satisfactorily  and the right ventricular ejection fraction [mean 47% (range: 40–56)]. The mean PR fraction was 49.4% (range: 40–59).The baseline imaging parameters are presented in Based on the guidance provided by preoperative 3D-printing technology, patients 1 and 2 were fitted with 44–26 mm devices, patients 3, 7, and 8 received 36–23 mm devices, and patients 4, 5, and 6 were given 32–23 mm devices. p = 0.762], but the PA diastolic pressure increased from 3.5  mmHg to 10  mmHg (p < 0.001). The peak transpulmonary valve gradient was decreased from 28.5  mmHg to 8.5  mmHg (p< 0.001) after the deployed device was viewed by TEE. Following the procedure, right heart catheterization parameters showed no significant change in PA systolic pressure . However, there was an increase in PA diastolic pressure from 3.5  mmHg to 10  mmHg (p < 0.001). No ventricular arrhythmias, device-related adverse events, regurgitation, or PVL above grade 2+ (≥mild) occurred following valve deployment. Two patients experienced minor postoperative hemoptysis, likely attributed to the sudden increase in PA pressure following device implantation and subsequent capillary rupture. However, all patients successfully recovered from this condition and were discharged from the intensive care unit within 2 days. Before discharge, the CTA data of patients were utilized for 3D reconstruction, and 3D models were printed to validate the postoperative morphology and functionality of the bioprostheses ]. MRI findings revealed a reversal of right ventricular remodeling, characterized by a significant reduction in the RVEDVI . Consequently, there was an improvement in the right ventricular ejection fraction , indicative of enhanced right ventricular function. Furthermore, there were continuous improvements in NYHA class, peak O2 levels, and 6-Minute Walk Test distances following the TPVR procedure, suggesting an enhancement in exercise capacity and overall quality of life , leading to favorable clinical outcomes for severe PR. In addition to routine imaging assessments, our preoperative guidance, utilizing cardiovascular 3D printing technology, facilitated the selection of appropriate device sizes and optimal implant sites by interventionalists.Severe PR following surgical repair of TOF is a life-threatening condition that often presents with chronic overload, resulting in significant right ventricular dysfunction and clinical symptoms ,2,9,18. Currently, the clinical use of balloon-expandable devices for TPVR is dominated primarily by two types: the Melody  and the SAPIEN platforms . However, the indications for enlarged nRVOT are still largely restricted by the diameter of the annulus (up to 29 mm) and the challenge of achieving stable landings . Prestenp-valve , which has demonstrated promising results in early clinical trials and has received the CE mark [These studies also underscore the importance of improved assessment of preoperative imaging data and the selection of appropriately sized devices, which significantly enhance the feasibility of TPVR in the context of an enlarged nRVOT. The pre-stenting approach, although effective, comes with certain drawbacks. It involves additional radiation exposure, leading to prolonged procedure times. Furthermore, a delay of several months in the secondary intervention of the prosthesis is necessary to allow for stent integration, ensuring stent stability . However CE mark ,25. Simi CE mark . Other v CE mark . These nFurthermore, cardiovascular 3D printing has found extensive applications not only in surgical guidance for congenital heart disease but also in the interventional treatment of structural heart disease, showcasing significant advancements ,14,15,16In another study, Shafkat et al.  employedWe utilized an enlarged nRVOT 3D-printed model to assess the feasibility of using the PT-Valve for TPVR and its unique advantages in this patient population. Following the implantation of the PT-Valve into the model, we observed that stable anchorage was achievable, even in cases with large nRVOT sizes and pyramidal RV–PA conduits. This result can be attributed to the self-expanding nature of the PT-Valve, which exerts minimal radial forces compared to balloon-expandable valves ,28. AddiThe PT-valve annular dimension is intentionally smaller than the diameter of the stent ends, which helps to prevent compression of the valve in the center of the stent and reduces the risk of valve distortion. This feature ensures an effective transvalvular gradient and promotes the long-term durability of the leaflets ,30. CurrWe successfully demonstrated the safety, efficacy, and feasibility of implanting PT-Valves in patients with an enlarged nRVOT for the treatment of severe PR. The bioprosthetic function and morphology were well maintained, as evidenced by the postoperative 30-day, 6-month, and 1-year follow-up data. The utilization of preoperative 3D-printing guidance played a crucial role in exploring the properties of the new device, selecting the appropriate size of bioprosthesis for patients with a complex enlarged nRVOT, visualizing the optimal landing position in the conduits, and predicting the risk of complications.


Aortic cross-clamp time and stress-induced changes in PE between rest and dobutamine dose of 10 µg/kg/min were the only independent predictors of CEPOP. An increase in LV entropy ≥ 1 on the dobutamine dose of 10µg/kg/min in comparison to rest investigation showed AUC = 0.853 . Conclusion: Stress-induced changes in PE obtained during low-dose dobutamine GBPS are associated with a complicated course of the early postoperative period after surgical treatment for ICM.(1) Objective: The objective of this study was to assess the prognostic value of stress-gated blood pool SPECT (GBPS) estimates in patients with ischemic cardiomyopathy (ICM) in the early postoperative period. (2) Methods: A total of 57 patients  with ICM and LV ejection fraction  were enrolled in the study. Before surgical treatment, all patients underwent GBPS . Stress-induced changes in left ventricular (LV) ejection fraction, peak ejection rate, volumes, and mechanical dyssynchrony , and phase histogram bandwidth) were estimated. Two-dimensional transthoracic echocardiography was performed baseline. Serum levels of NT-proBNP were analyzed with enzyme-linked immunoassay. (3) Results: After surgical treatment, patients were divided into two groups, one, with death, the need for an intra-aortic balloon pump (IABP) or/and inotropic support with a stay in the intensive care unit for more than two days and two, without complications in the early postoperative period (EPOP). Complicated EPOP (CEPOP) was observed in 17 (30%) patients , and 40 patients had no complications (NCEPOP). GBPS showed differences in LV EDV (mL) (321  vs. 268 ,  Surgical treatment for ischemic cardiomyopathy (ICM) remains a challenging task. These patients are at high risk of a complicated course of the early postoperative period . Low carThere are some data about preoperative and intraoperative predictors of LCOS ,5. The pPhase analysis based on cardiac single photon emission computed tomography (SPECT) data, reflecting ventricular mechanical dyssynchrony (MD), is a very promising and rapidly developing tool due to its high reproducibility and almost complete automation ,7,8. ThiThe objective of the present study was to determine the prognostic value of dobutamine-induced LV MD to predict LCOS and cardiac death in the early postoperative period after surgical treatment for ICM.A total of 77 patients scheduled for surgical treatments for ICM who underwent low dobutamine dose (LDD) gated blood pool SPECT (GBPS) were prospectively enrolled in the study between 2018 and 2020. The inclusion criteria were the following. Reduced LV systolic function (LVEF < 40%) and an increase in LV volumes using the 2-dimensional transthoracic echocardiography (TTE) data, history of myocardial infarction, more or equal to 75% stenosis of left main or ≥75% stenosis in the proximal left anterior descending artery, and/or stenosis of ≥75% of two or more epicardial vessels based on invasive coronary angiography results [Patients who had contraindications to the LDD stress test, such as acute coronary syndrome, severe aortic valve stenosis, hypertrophic cardiomyopathy, hemodynamic instability, inflammatory myocardial disease, atrial fibrillation, severe hematological or neurological disorders, and patients who did not sign the informed consent were excluded from the study .According to the research protocol, all patients underwent LDD GBPS within 3 days prior to surgery. In the early postoperative period , the patients were divided into two groups: (1) patients with complications in the early postoperative period (CEPOP) and (2) those with no early postoperative complications (NCEPOP).The primary endpoint of this study was a composite of LCOS  and/or inotropic support requiring more than 2 days in the intensive care unit and/or cardiac death within 30 days after surgery ,17.This research is part of the SciCoRIC study . The study was approved by the Local Ethical Committee and conformed to the Declaration of Helsinki on Human Research. Written informed consent was obtained from each patient after an explanation of the protocol, its aims, and potential risks.99mTc-pertechnetate dose of approximately 9 MBq/kg Corbett, et al. [The protocol of stress testing and GPBS data acquisition and processing have been described in detail in our previous article . Briefly, et al. , patientAll examinations were performed using a dedicated cardiac CZT-SPECT gamma camera Discovery NM/CT 570c . A syringe pump, Braun Perfusor Compact S , was used for the infusion of dobutamine.Raw data were analyzed visually for motion and attenuation artifacts. Quality control was performed according to the European Association of Nuclear Medicine guidelines . Images Reconstructed images were processed using the Quantitative Blood Pool SPECT 2009.0  software. Ventricular contours, mitral, and tricuspid valves plane were adjusted manually when required. The count-based volumes method was used to calculate end-diastolic volume (EDV), end-systolic volume (ESV), as well as EF Corbett, et al. . The folPreoperative preparation and intraoperative monitoring were standard. The surgical concept when performing surgical interventions strictly obeyed the “triple V” principle . SurgicaEchocardiography was performed for all patients according to a standard protocol using an EPIQ device . The structures of the heart were visualized using B-scan according to the standard technique. All measurements were taken while patients were at rest and in the left lateral decubitus position and by following recommendations for cardiac chamber quantification by echocardiography in adults endorsed by the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI) . A singlBlood samples were obtained by venipuncture, and adequate centrifuged serum samples were stored at −26 °C with a single freeze–thaw cycle. Serum levels of NT-proBNP were analyzed with enzyme-linked immunoassay .2 or Fisher’s exact tests were used for categorical variables. Friedman ANOVA was used to reveal differences in GBPS parameters measured during the entire study, at rest and for 10 and 15 µg/kg/min of dobutamine. When the difference was statistically significant, a post-hoc paired comparison was applied using the Wilcoxon signed rank test with Bonferroni correction for multiple comparisons. Each statistical test was 2-sided, and a p-value of <0.05 was considered statistically significant.Data were assessed for normal distribution using the Shapiro–Wilk test. Continuous variables were expressed as mean ± standard deviation (SD) or as median with interquartile range (IQR) (Q25 to Q75). Differences between independent groups were determined using the Mann–Whitney U test, and Wilcoxon signed-rank tests were performed for unpaired and paired data, respectively. The χp < 0.05 and a removal criterion of p > 0.1.A logistic regression analysis was performed to assess the relationship between parameters and the course of EPOP. Independent predictors of CEPOP were evaluated using forward-stepwise logistic regression analysis with an entry criterion of Receiver-operating characteristic (ROC) curves were analyzed to determine the optimal cut-off values and diagnostic performance , and negative (NPV) predictive values) to predict CEPOP. Statistical analyses were performed using STATISTICA 10.0  and MedCalc 17.4 .n = 6), excessive hypertensive response (n = 6), and heart rhythm disturbances (n = 4) resulting in test termination and 2 patients had surgery canceled. As a result, 57 ICM patients  were included in the final analysis  and lower values of ESV (p = 0.01) as well as longer aortic cross-clamp (XCL) time (p = 0.04), as compared to NCEPOP patients  patients who had complications in the early postoperative period  formed the CEPOP group, whereas 40 (70%) had no complications and formed the NCEPOP group. The clinical characteristics of the patient sample are presented in patients . All patp = 0.007) and ESV (p = 0.006) in comparison to NCEPOP   . Neverth/kg/min) . The GBPp < 0.001 and OR = 1.02, CI 1.001–1.05; p < 0.001, respectively).The result of univariate and multivariate logistic regression analyses are shown in p < 0.0001) and XCL time > 118 min showed AUC = 0.672  in the prediction of complicated EPOP  = 0.853  An increase in LV PE during the dobutamine stress test is associated with complicated EPOP in patients after surgical treatment of ICM and comprises LCOS and cardiac death. (2) A dobutamine dose of 10 µg/kg/min is sufficient to identify patients at high risk of LCOS and cardiac death. To the best of our knowledge, this is the first study that reveals the association between stress-induced changes in mechanical dyssynchrony obtained from GBPS with a CZT gamma camera and adverse EPOP in patients with ICM.Although MD can be assessed with multiple radiation-free imaging techniques, such as TTE and cardiac magnetic resonance, there are some crucial advantages of nuclear modalities in this area. SPECT has the lowest inta- and inter-observer variability; acquisition is relatively fast and provides the operator with information about perfusion along with contractile function ,7,14. AdSeveral previous studies showed a prognostic value of MD revealed by nuclear modalities in different cardiac pathologies ,21,22,232+ from the cytoplasm into the sarcoplasmic reticulum [Interest in the study of PE is growing rapidly. This is a rather “young” parameter, reflecting the degree of phase histogram disorder ,30. The eticulum .p < 0.001) [p = 0.039), while neither MD indices obtained by positron emission computed tomography nor QRS duration showed any predictive value [p = 0.047) [The prognostic value of PE at rest has been shown previously regarding several specific groups of patients. In patients with complete left bundle branch block, with LVEF = 49.2% and normal LV volumes, PE ≥ 79% was associated with adverse cardiac events over a 2-year follow-up  . In ICM ve value . These dve value  and diffve value , respectMD can be underestimated at rest. Stress tests are usually used to reveal MD, especially in CAD . HoweverOnly a few investigations acquired SPECT data directly during the stress test ,39,40. IThe current work provides new insight into the prognostic value of MD. This study revealed that the increase in PE at a dobutamine dose of 10 µg/kg/min, measured before surgery, was associated with complicated EPOP  after surgical treatment of ICM. The exact mechanism of association between PE and adverse EPOP is difficult to determine. Most interventions implying cardiopulmonary bypass with cardioplegic arrest or XCL could lead to myocardial dysfunction due to ischemic/reperfusion injury . It is kThis study revealed that a dobutamine dose of 10 µg/kg/min is sufficient for the evaluation of patients at high risk after surgical treatment for ICM. The existing differences in PE stress-induced changes between groups appeared at this dose, while further dose increases did not cause any significant changes. In our previous study, we showed that a dobutamine dosage of 10 µg/kg/min is enough to evaluate stress-induced changes in LVMD in ICM patients , which iStress-induced changes in LV PE by preoperative low-dose dobutamine GBPS are associated with the complicated course of the early postoperative period after surgical treatment for ICM.The rise in PE values at a dobutamine dose of 10 μg/kg/min is the independent predictor of the adverse early postoperative period, while a further increase in the dose had no additional prognostic value. Further large-scale clinical studies are needed to evaluate the potential clinical significance of this approach in patients with severe heart failure.This is a single-center study with a relatively small number of patients; nevertheless, it demonstrates the feasibility and potential of stress GBPS to predict early postoperative complications after surgical treatment of ICM. The absence of a control group not undergoing CABG limits the clinical translation of the study findings. In the present study, we assessed LV contractile function based on 5 min data acquisition. While there may be some averaging of the contractile function during this acquisition time, its effect, particularly at 10 and 15 μg/kg/min of dobutamine, can be considered insignificant because of dobutamine saturation at the dose of 5µg/kg/min. We used global parameters of LV mechanical synchrony and did not take into consideration the location of the infarct zone and the regional parameters.