Cancer treatment might cause heart failure and deteriorate the patients’ quality of life. Despite the wide use of conventional echocardiography, it often fails to detect cardiotoxicity until advanced cardiac dysfunction at potentially irreversible stages. Advanced techniques, such as three-dimensional imaging and strain analysis in stress echocardiography, have shown promise in identifying cardiotoxicity at subclinical stages, even when traditional measures remain within normal ranges. These novel techniques have been shown to identify cardiac impairment in 30%–50% of the patients undergoing potentially cardiotoxic chemotherapy, which allows for early intervention and enhanced patient management. Although professional societies are advocating for the inclusion of these techniques into routine monitoring protocols, more research is needed to optimize and standardize their use across various centers and chemotherapeutic agents. This review explores the role of stress echocardiography in the early detection and monitoring of chemotherapy-induced cardiotoxicity. It delves into current knowledge and emerging research, aiming to provide a comprehensive understanding and to highlight areas worthy of further investigation.

Left ventricular (LV) function is typically evaluated through LV ejection fraction (EF), a robust indicator of risk, showing a nonlinear increase in mortality rates below 40%. Conversely, excessively high EF values (> 65%) also correlate with elevated mortality, following a U-shaped curve, with its nadir observed between 50% and 65%. This underscores the necessity for improved identification of the hypercontractile phenotype. However, EF is not synonymous with LV contraction function, as it can fluctuate independently of contractility due to variations in afterload, preload, heart rate, and ventricular-arterial coupling. Assessing the contractile status of the LV requires more specific metrics, such as LV elastance (or contractile force) and global longitudinal strain. Current guidelines outline various parameters for a more precise characterization of LV contractility, yet further research is warranted for validation. The true hypercontractile phenotype is evident in cardiac pathologies such as hypertrophic cardiomyopathy, ischemia with angiographically normal coronary arteries, Tako-tsubo syndrome, heart failure with preserved EF, and may also stem from systemic disorders including anemia, hyperthyroidism, liver, kidney, or pulmonary diseases. The hypercontractile phenotype constitutes a distinctive hemodynamic substrate underlying clinical manifestations such as angina, dyspnea, or arrhythmias, presenting a target for intervention through beta-blockers or specific cardiac myosin inhibitors. While EF remains pivotal for clinical classification, risk stratification, and therapeutic decision-making, integrating it with other indices of LV function can enhance the characterization of the hypercontractile phenotype.

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous entity including patients with different phenotypes of near normal, normal, and supernormal left ventricular (LV) function. To assess the value of resting LV elastance (also known as force) with transthoracic echocardiography (TTE) to identify HFpEF phenotypes. In a prospective, observational, multicenter study, 2380 HFpEF patients were recruited from July 2016 to May 2024. Systolic blood pressure (SBP) was measured. We assessed LV end-diastolic volume (EDV), end-systolic volume (ESV), EF, force (SBP/ESV), stroke volume (SV), arterial elastance (AE), ventricular-arterial coupling (VAC), and left atrial volume index (LAVI). Global longitudinal strain (GLS) was available in 1164 (48.9%) patients. 680 patients finished follow-up with a composite end-point of major adverse cardiac events (MACEs). Patients were divided into three groups: low force (< 25^th percentile, Group 1, < 3.24 mmHg/ml), intermediate force (≥ 25^th percentile and ≤ 75 ^th percentile, Group 2, 3.24-5.48 mmHg/ml), and high force (> 75 ^th percentile, Group 3, >5.48 mmHg/ml). The 3 groups showed a gradient with descending values (Group 3>2>1) for SBP, EF, GLS, AE, and VAC, with the opposite gradient (Group 1> 2> 3) for EDV, ESV, SV, and LAVI values (all P<0.01). After a median follow-up of 16 months, 205 MACEs occurred in 138 patients. Cumulative MACEs rate was lowest in group 2 (14.7% person-year), higher in group 1 (16.1% person-year) and 3 (22.9% person-year, log rank p = 0.036). HFpEF patients present with different LV contractile phenotypes, easily identified with resting LV force and volumetric TTE. The dominant hemodynamic feature of hypocontractile phenotype is a preload recruitment with larger LV EDV and normal SV, while the hypercontractile phenotype is characterized by a small LV with reduced SV. The hypercontractile and hypocontractile phenotypes are associated with a higher risk of subsequent events.

Objective: The left atrial stiffness index (LASI) holds significance in the atrioventricular coupling function and heart failure progression. To assess left atrial function and evaluate the relationship between LASI and exercise capacity in hypertension-related heart failure with preserved ejection fraction (HT-HFpEF).Methods: The study involved 62 healthy subjects and 163 patients with HT (112 patients in simple HT group and 51 patients in HT-HFpEF group). Each patient performed exercise stress test and standard ultrasonic images were evaluated. A comprehensive evaluation of atrioventricular function, along with investigation into the correlation between these functional parameters and exercise capacity. And further to investigate the feasibility of predicting exercise intolerance using three-dimensional derived left atrial strain index (LASI) (E/e'/LASr and E/e'/LASr-c).Results: Compared to healthy subjects, HT group demonstrated the elevation in left atrial volume accompanied by decrease in strain value (P < 0.05). In HT-HFpEF group, further significant reductions were observed in both longitudinal (LASr) and circumferential strain (LASr-c, LASct-c) (P < 0.05). Univariate regression demonstrated that both E/e'/LASr and E/e'/LASr-c were significantly correlated with metabolic equivalents (METs) (r = −0.462, P < 0.001; r = −0.381, P < 0.001). The E/e'/LASr demonstrates comparable diagnostic efficacy to exercise-E/e' in assessing exercise intolerance in HT-HFpEF patients (AUC: 0.836 vs. 0.867, P = 0.239).Conclusion: Progressive LA remodeling contributes to decreased atrioventricular compliance in HT and HT-HFpEF patients.E/e'/LASr serves as an independent indicator of exercise intolerance in patients with HT-HFpEF.

Transthoracic echocardiography (TTE) is widely recognized as one of the principal modalities for diagnosing tricuspid regurgitation (TR). The diagnostic procedures associated with conventional methods are intricate and labor-intensive, with human errors leading to measurement variability, with outcomes critically dependent on the operators’ diagnostic expertise. In this study, we present an innovative assessment methodology for evaluating TR severity utilizing an end-to-end deep learning system. This deep learning system comprises a segmentation model of single cardiac cycle TR continuous wave (CW) Doppler spectra and a classification model of the spectra, trained on the TR CW Doppler spectra from a cohort of 11,654 patients. The efficacy of this intelligent assessment methodology was validated on 1500 internal cases and 573 external cases. The receiver operating characteristic (ROC) curves of the internal validation results indicate that the deep learning system achieved the areas under curve (AUCs) of 0.88, 0.84, and 0.89 for mild, moderate, and severe TR, respectively. The ROC curves of the external validation results demonstrate that the system attained the AUCs of 0.86, 0.79, and 0.87 for mild, moderate, and severe TR, respectively. Our study results confirm the feasibility and efficacy of this novel intelligent assessment method for TR severity.