I. Scalia

Left Ventricular Global Strain Analysis by Two-Dimensional Speckle-Tracking Echocardiography: The Learning Curve

Background The application of left ventricular (LV) global strain by speckle‐tracking is becoming more widespread, with the potential for incorporation into routine clinical echocardiography in selected patients. There are no guidelines or recommendations for the training requirements to achieve competency. The aim of this study was to determine the learning curve for global strain analysis and determine the number of studies that are required for independent reporting. Methods Three groups of novice observers (cardiology fellows, cardiac sonographers, medical students) received the same standardized training module prior to undertaking retrospective global strain analysis on 100 patients over a period of 3 months. To assess the effect of learning, quartiles of 25 patients were read successively by each blinded observer, and the results were compared to expert for correlation. Results Global longitudinal strain (GLS) had uniform learning curves and was the easiest to learn, requiring a minimum of 50 patients to achieve expert competency (intraclass correlation coefficient > 0.9) in all three groups over a period of 3 months. Prior background knowledge in echocardiography is an influential factor affecting the learning for interobserver reproducibility and time efficiency. Short‐axis strain analysis using global circumferential stain and global radial strain did not yield a comprehensive learning curve, and expert level was not achieved by the end of the study. Conclusions There is a significant learning curve associated with LV strain analysis. We recommend a minimum of 50 studies for training to achieve competency in GLS analysis. HighlightsThere are no current guidelines on training and competency for strain analysis.There is a learning curve for global longitudinal strain analysis.Minimum requirement of 50 studies recommended to achieve competency.Background in echocardiography influences interobserver reproducibility and time efficiency.

Acute life-threatening reversible pulmonary vasoconstrictive reaction to bleomycin chemotherapy demonstrating the clinical application of ePLAR - echocardiographic Pulmonary to Left Atrial Ratio.

Lung toxicity arising from the chemotherapeutic agent bleomycin typicallymanifests a spectrumof chronic pulmonary syndromes including interstitial pneumonitis, hypersensitivity pneumonitis, eosinophilic pneumonia and progressive interstitial fibrosis. We report a rare case of acute pulmonary hypertension associated with bleomycin administration, which emphasises the clinical relevance and applicability of the recently described, non-invasive echocardiographic parameter ePLAR (echocardiographic Pulmonary to Left Atrial Ratio). Right heart catheterisation has historically remained the gold standard for distinguishing pre-capillary pulmonary hypertension (high mean pulmonary pressure, normal pulmonary wedge pressure), from post-capillary pulmonary hypertension (elevated pulmonary wedge pressure). The echocardiographic parameter, ePLAR, is a non-invasive method of predicting the pressure gradient across the pulmonary vasculature [1,2]. This parameter is calculated from the maximum tricuspid regurgitation continuous-wave Doppler velocity (m/s) divided by the transmitral E-wave septal: mitral annular DTI e’-wave ratio (ePLAR (m/s) = TRVmax (m/s)/E/e’) – See Fig. 1A. Increasing ePLAR values suggest increasing trans-pulmonary gradient (TPG),whilst lower ePLAR values indicate elevated left heart pressures as the driver for elevated pulmonary pressures. A 70-year-old man was diagnosed with Hodgkins lymphoma requiring six cycles of systemic chemotherapy with doxorubicin, bleomycin, vincristine and dacarbazine. Baseline cardiac and respiratory

Dramatic Normalization of the Echocardiographic Pulmonary–to–Left Atrial Ratio with Thrombolysis in a Case of Life-Threatening Submassive Pulmonary Emboli

Graphical abstract

ePLAR: the echocardiographic pulmonary to left atrial ratio - conceptualising a new parameter for the assessment of pulmonary hypertension. Foundation data from 16,356 normal echocardiograms

Background: ePLAR = TRVmax/E:E’ (maximum tricuspid regurgitation continuous wave Doppler velocity divided by the transmitral E wave: mitral annular DTI E’ wave ratio) is proposed for differentiating pre-capillary pulmonary hypertension (Pre-cap PHT high trans-pulmonary gradient, normal pulmonary wedge pressure) from post-capillary physiology (Post-cap elevatedwedge pressure, +/elevated trans-pulmonary gradient) secondary to left heart disease. Methods: Patients with right ventricular systolic pressure >35mmHg were classified by right heart catheterisation as pre-cap, post-cap PHT or not pulmonary hypertensive (mean pulmonary arterypressure 0.23 had high discriminatory power by ROC analysis (AUC = 0.832). The ePLAR for 1000 population normal echocardiograms (mean age 56±16yrs) was 0.30±0.09. Conclusions: ePLAR is a simple echocardiographic parameter which can accurately differentiate pre-capillary pulmonary hypertension from the more common postcapillary aetiology. The use of ePLAR has the potential to streamline screening of patients for specific pulmonary vasodilator therapy.