OBJECTIVE: This study aimed at assessing the changes of left atrial (LA) volume and strain function in metabolic syndrome (MS) patients using four-dimensional automatic left atrial quantification (4D-LAQ) and exploring independent correlative factors for LA function.
METHODS: A total of 110 MS patients and 70 normal controls were selected and assigned into the MS group and the control group, respectively. Echocardiogram parameters were routinely examined and the thickness of epicardial adipose tissue (EAT) were measured with a parasternal long axis of left ventricle(LV). The LA volume and strain parameters were determined using 4D-LAQ. The independent correlation factors for LA strain parameters in MS patients were investigated through linear regression analysis.
RESULTS: Compared with the control group, LA volume parameters were increased in the MS group, LA strain parameters and LA emptying fraction (LAEF) were decreased (all P < 0.05). EAT thickness is associated with LA reservoir longitudinal strain (LASr), conduit longitudinal strain (LAScd), reservoir circumferential strain (LASr-c), and conduit circumferential strain (LAScd-c) (all P < 0.05). LA contraction longitudinal (LASct) and circumferential strain (LASct-c) were not statistically significant. Regression analysis results show that systolic blood pressure (SBP) and triglyceride (TG) are independent correlative factors. Intra-observer and inter-observer repeatability test showed that the LA parameters examined by 4D-LAQ had good agreement.
CONCLUSIONS: 4D-LAQ is capable of effectively assessing the LA function in MS patients and providing a useful reference for clinical diagnosis. SBP and TG serve as the independent correlative factors for LA function.

Cardiac magnetic resonance imaging is the gold standard to detect cardiac iron overload in patients with beta-thalassemia. The aim of this study was to evaluate cardiac iron overload using four-dimensional transthoracic echocardiography in thalassemia patients with and without cardiac involvement detected by T2* value and to compare the two techniques. This cross-sectional and observational study was conducted in 44 patients diagnosed with thalassemia major. Left ventricular systolic function was assessed using four-dimensional speckle tracking echocardiography-derived global longitudinal (GLS), circumferential, radial, and area strain indices. Left ventricular ejection fraction, volumes, and mass index were similar between the patients with T2* values less than 20 ms as compared to those with T2* values greater than 20 ms. However, patients with lower T2* values had significantly higher GLS values (- 17.0% vs. - 19.8%, p < 0.001) compared with those with higher T2* values. GLS demonstrated a sensitivity of 91.7% and a specificity of 71.9% at a cut-off value of - 18.5%; however, sensitivity was 75%, and the specificity was 84.4% at a cut-off value of - 17.5%. For - 18.5%, the positive predictive value was 55%, and the negative predictive value was 95.8%; for - 17.5%, these values were 64.2 and 90%, respectively. This novel echocardiographic method, tested for the first time in our study in comparison with cardiac MRI in an adult patient group, has been shown to predict cardiac iron overload in thalassemia patients in the subclinical period without LVEF decline. Four-dimensional GLS is a marker with high sensitivity and negative predictive value.

BACKGROUND: Hemodynamic load and heart structural remodeling rise during pregnancy because these changes are physiologically necessary. Adaptations in the mother\'s circulatory system may either initiate or aggravate the development of cardiovascular disease in the offspring. If the body is unable to adjust to these changes, it may develop heart conditions like cardiomyopathy. There is a lack of third-trimester echocardiographic data on left ventricular (LV) volume and function in healthy Iraqi women. To understand the cardiac alterations that occur during normal pregnancy, a precise tool that evaluates cardiac function is needed. In that regard, the four-dimensional echocardiography (4DE) technique has markedly improved the quality and accuracy of assessing the size and function of the left ventricle.
OBJECTIVE: The present study aimed to assess LV volume and function in the third trimester of a healthy pregnancy using 4DE and to compare the results of LV assessment using 4DE with those of LV assessment using conventional two-dimensional (2D) echocardiography.
METHODS: The study was conducted on 75 healthy pregnant women (the case group) and 75 non-pregnant women (the control group). The participants attended Al-Fortat Teaching Hospital from April 1, 2022, to May 30, 2023, and had 2D and 4D echocardiographic studies performed on them.
RESULTS: The LV end-diastolic volume (EDV), end-systolic volume (ESV), and cardiac output (CO) were significantly increased in the case group compared to the control group (90.87 ± 18.03 ml vs. 62.64 ± 14.11 ml, P<0.001; 35.59 ± 6.52 ml vs. 22.42 ± 5.82 ml, P<0.001; and 4.87 ± 1.27 vs. 3.35 ± 0.87 L/m, P<0.001, respectively). In contrast, the LV ejection fraction (LVEF) was significantly decreased in the pregnant group compared to the control group (60.37 ± 5.42 % vs. 64.04 ± 4.99 %, P<0.01). Additionally, the study showed significant differences in EDV, ESV, ejection fraction (EF%), and CO (P<0.001) between 2D and 4D echocardiography, according to the Bland Altman test.
CONCLUSIONS: In healthy pregnant women in their third trimester, there is an increase in the indicators of preload (ventricular volume and CO) and a decrease in EF%. The 4DE provides detailed images and information about cardiac volumes and function, allowing for the early detection of any potential problems that may arise during pregnancy and thus improving the health outcomes of both the mother and the developing fetus.

BACKGROUND: Thyroid disorders are associated with many cardiovascular risk factors. The importance of thyroid hormones in the pathophysiology of heart failure is underlined by the European guidelines of the European Society of Cardiology. However, the role of subclinical hyperthyroidism (SCH) in subclinical left ventricular (LV) systolic dysfunction is not entirely clear.
METHODS: This cross-sectional study included 56 SCH patients and 40 healthy volunteers. The 56 SCH group was divided into two subgroups depending on the presence of fragmented QRS (fQRS). In both groups, left ventricular global area strain (LV-GAS), global radial strain (GRS), global longitudinal strain (GLS), and global circumferential strain (GCS) were obtained with four-dimensional (4D) echocardiography.
RESULTS: GAS, GRS, GLS, and GCS values were significantly different in SCH patients and in healthy volunteers. GLS and GAS values were lower in the fQRS+ than in the fQRS- group (-17.06 ± 1.00 vs. -19.08 ± 1.71, p < .001, and -26.61 ± 2.38 vs. -30.61 ± 2.57, p < .001, respectively). ProBNP was positively correlated with LV-GLS (r = 0.278, p = .006) and LV-GAS (r = 0.357, p < .001). Multiple linear regression analysis showed that fQRS was an independent predictor of LV-GAS.
CONCLUSIONS: 4D strain echocardiography may be helpful for the prediction of early cardiac dysfunction in patients with SCH. The presence of fQRS may be an indicator of subclinical LV dysfunction in SCH.

Tricuspid annulus (TA) geometry and function reference values are limited, especially for Asian populations. We aimed to explore TA using four-dimensional echocardiography (4DE) in a healthy Asian population.
A total of 355 healthy Asian volunteers (median age 34 years; 52% males) were prospectively enrolled. TA geometry and function were analyzed using 4DE throughout the cardiac cycle.
The TA area, perimeter, and dimensions were smallest at end systole (ES) and largest at late diastole (LD). Normal TA parameters at end diastole (ED) in different sex and age groups were obtained. TA areas, perimeters, and dimensions in males were significantly larger than those in females at ED; BSA-indexed perimeters and BSA-indexed dimensions in males were significantly smaller than those in females at ED. TA parameters correlated well with tricuspid valve (TV) tenting, right ventricle (RV), and right atrium (RA) parameters.
Reference values of TA parameters were obtained by 4DE in an Asian population. Quantitative data on TA geometry and function are essential for TA pathology and therapeutics.

OBJECTIVE: This study aimed to evaluate the role of real-time three-dimensional (four-dimensional) and speckle tracking echocardiography for early detection of left ventricular systolic dysfunction and also for the relationship between myocardial deformation parameters and myocardial iron load which is measured by cardiac magnetic resonance relaxation time T2* values in asymptomatic children with beta-thalassemia major.
METHODS: This multicenter cross-sectional study included 40 patients (mean age 15.4 ± 2.9, 42.1% male) and 40 healthy children whose age, gender, and body mass index-matched with patients. Each participant underwent conventional echocardiography and tissue Doppler imaging. Left ventricular ejection fraction; global longitudinal, circumferential, radial strains; twist; and torsion were measured by real-time three-dimensional and speckle tracking echocardiography. Cardiac magnetic resonance imaging T2* was measured in patients.
RESULTS: Left ventricular global longitudinal, circumferential, and radial strains were decreased despite preserved global ventricular function in patients compared to healthy children (p = p = .029, p = p < .001, p = .003, respectively). There were no statistically significant differences between patients with T2* ≥ 20 ms and patients with T2* < 20 ms for all echocardiographic parameters. Also, there were no significant correlations between all echocardiographic parameters and T2* values in all patients, those with T2* ≥ 20 ms, and T2* < 20 ms.
CONCLUSIONS: We found that even in asymptomatic children with beta-thalassemia major, left ventricular longitudinal, circumferential and, radial functions were impaired by real-time three-dimensional (four-dimensional) and speckle tracking echocardiography. This novel echocardiographic method might be an important tool for detecting subclinical left ventricular systolic dysfunction irrespective of T2* values.

This is a case-control study of our experience of mid-term follow-up of 40 children who had a transcatheter closure of very large atrial septal defects group (1). All cases had an atrial septal defect device size more than 1.5 times their weight, a ratio considered a contraindication for trans catheter closure (TCC) in some previous reports. The aim of this study is to report the outcomes and mid-term follow-up of transcatheter closure of large atrial septal defects using two-dimensional conventional echocardiography, tissue Doppler imaging, and four-dimensional speckle tracking imaging, and as such to compare results of same echocardiographic examination of age-matched control group of 40 healthy children group (2). Cardiac MRI was performed on cases group (1) only to detect right ventricle and left ventricle volumes and function and early signs of complications. There was no difference between cases and matched healthy controls in terms of the assessment of left ventricle and right ventricle by two-dimensional echocardiography, tissue Doppler imaging, and four-dimensional speckle tracking imaging. Similarly, there was no statistically significant difference between four-dimensional echocardiography and cardiac MRI in their respective assessment of both left ventricle and right ventricle volumes and function. We also detected no complications by echo or by cardiac MRI after a median follow-up period of 2 years and recorded a complete remodelling of right ventricle volumes in all children studied. This points to the safety and efficiency of transcatheter closure of large atrial septal defects in children on mid-term follow-up.

OBJECTIVE: This study aimed to evaluate the role of real-time three-dimensional (known as four-dimensional) echocardiography and three-dimensional speckle-tracking echocardiography for the early detection of left ventricular systolic dysfunction in asymptomatic children with type 1 diabetes mellitus.
METHODS: This cross-sectional study included 38 patients (mean age 15.4 ± 2.9, 42.1% male) and 38 age, gender, and body measurements matched healthy children. Each patient underwent an interview about medical history, a detailed clinical examination, blood laboratory tests, conventional echocardiography, and tissue Doppler imaging. Left ventricular ejection fraction; global longitudinal, circumferential, radial strain; twist; and torsion were measured by real-time three-dimensional and speckle-tracking echocardiography.
RESULTS: Conventional echocardiography and tissue Doppler imaging showed normal left ventricular systolic function in the patients. Although left ventricular ejection fraction (61.6 ± 1.4%, 61.8 ± 1.1%, p = 0.386), global longitudinal [-26.6 (-27.7 to -26.1)%, -26.2 (-27.7 to -24.9)%, p = 0.224], and radial strain [44.4 (42.4-45.9)%, 43.9 (41-46.1)%, p = 0.513] were similar to the controls, circumferential strain (-27.3 ± 1.3%, -28.0 ± 1.6%, p = 0.048) and twist (9.5 ± 2.3°, 11.4 ± 3.0°, p = 0.003) were decreased in the patients compared with controls.
CONCLUSIONS: We found that even in children with asymptomatic type 1 diabetes mellitus with normal left ventricular ejection fraction, circumferential function was impaired and rotation pattern was changed. This novel echocardiographic method might be an important tool for detecting left ventricular systolic dysfunction in type 1 diabetes mellitus children before it becomes overt on conventional echocardiography and tissue Doppler imaging.

Echocardiography is a time and cost-effective imaging modality, providing evidence of myocardial ischemia by detecting the regional wall motion abnormalities (RWMA). However, quite a few coronary heart disease (CHD) patients do not present RWMA. The left atrium (LA) plays an irreplaceable role in determining the prognosis and risk stratification of cardiovascular disease including CHD. In this present study, we intend to explore the myocardial mechanics changes of LA mainly using four-dimensional (4D) LA quantitative volume-strain in CHD patients without RWMA at rest but were confirmed by coronary angiography (CAG) and to figure out several variables of the LA that could contribute to the identification of those patients.
We prospectively enrolled 76 patients who underwent two-dimensional echocardiography (2DE), four-dimensional echocardiography (4DE), and CAG for suspected CHD but without echocardiographic visible RWMA at rest. Patients diagnosed with CHD by CAG were furtherly divided into three groups according to the extent of coronary stenosis accessed by Gensini score (GS) as the mild, moderate, and severe CHD group. Twenty-four subjects with negative CAG results served as the control group. LA end-systolic anteroposterior diameter (LAAPD) and biplane LV ejection fraction (Biplane LVEF) were measured by 2DE; LA maximum volume (LAVmax), LA minimum volume (LAVmin), LA volume at the onset of atrial contraction (LAVpreA), LAVmax index (LAVmaxI), LA ejection volume (LAEV), LA ejection fraction (LAEF) accompanied by LA longitudinal strain during reservoir phase (LASr), conduit phase (LAScd), contraction phase (LASct) and LA circumferential strain during reservoir phase (LASr_c), conduit phase (LAScd_c), contraction phase (LASct_c) were measured by 4DE automatically. We compared these parameters between groups, explored how they change and whether they are related to the CHD severity.
LAEF, LASr_c, and LASct_c was lower in CHD group compared with the control group (p = .031, .002, .004, respectively). Pearson correlation analysis showed that LASr, LASct, LASr_c, and LASct_c negatively correlated with the GS. Additionally, LASr of patients in the severe CHD group decreased significantly compared with those in the mild CHD group, moderate CHD group, and control group, demonstrating the highest area under the receiver operating characteristic (ROC) curve (AUC) (AUC = .736 [p = .003, 95% CI .589-.884], sensitivity 67.8%, specificity 70.6%) with the cut-off value of 17.5% for predicting severe CHD patients.
Four-dimensional LA strain may provide new insight into identification and management for CHD patients and correlate with CHD severity. LASr showed good sensitivity (67.8%) and specificity (70.6%) for diagnosing severe CHD individuals.

OBJECTIVE: The left and right ventricular dysfunction are important clinical course indicators in patients with repaired tetralogy of Fallot. This study aimed to evaluate ventricular volumes, functions, and myocardial deformation in children with repaired tetralogy of Fallot by real-time three-dimensional (four-dimensional) echocardiography and compared with healthy children. It also aimed to investigate the relationships between ventricular volumes, functions, and myocardial deformation parameters in the patients.
METHODS: In this cross-sectional study, 35 patients (mean age 15.1 ± 2.8 years, 54% male) and 35 healthy controls of similar age, gender, and body measurements underwent echocardiography. End-diastolic volume index, end-systolic volume index, and ejection fractions of both ventricles; global longitudinal, circumferential, radial strain, twist, and torsion of the left ventricle; the longitudinal strain of the right ventricle free wall and septum were measured.
RESULTS: Left ventricular ejection fraction, global circumferential and radial strain, twist and torsion were significantly lower in patients compared with controls. Left ventricular ejection fraction correlated with global circumferential (r = -0.446, p < 0.001) and radial strain (r = -0.433, p < 0.001) in the patients. Right ventricular volumes were significantly higher, and ejection fraction was significantly lower in patients compared with controls. All right ventricular parameters correlated with each other in the patients.
CONCLUSIONS: Left ventricular contraction pattern was changed, circumferential and radial fibres were most affected in the patients. Right ventricular dilatation and dysfunction were detected, and right ventricular ejection fraction correlated well with strain measurements of the right ventricle.