Showing papers in "Journal of Echocardiography in 2017"
TL;DR: Investigation of the frequency and characteristics of mitral annular disjunction in the patients referred to an echocardiography laboratory and to compare these with previously reported pathological data found it to be detected not only in patients with a myxomatous mitral valve but also in normal cases.
Abstract: Mitral annular disjunction is a structural abnormality of the mitral annulus fibrosus and is pathologically defined by a separation between the atrial wall–mitral valve junction and the left ventricular attachment. Mitral annular disjunction can cause hypermobility of the mitral valve apparatus and is often associated with mitral valve prolapse (MVP). The aim of this study was to investigate the frequency and characteristics of mitral annular disjunction in the patients referred to an echocardiography laboratory and to compare these with previously reported pathological data. We retrospectively studied 1439 patients (mean age 65 ± 17 years, 58% male) referred to our echocardiography laboratory from 6 January 2014 to 31 March 2014. The echocardiographic parameters were compared between the patients with and without mitral annular disjunction. There were 125 cases (8.7%) with mitral annular disjunction, of which 15 (12%) also had MVP. The number of MVP patients in the group with mitral annular disjunction was significantly larger than in the group without mitral annular disjunction (p < 0.0001). The grade of mitral regurgitation was not significantly different between the two groups. Mitral annular disjunction was detected not only in patients with a myxomatous mitral valve but also in normal cases. The number of MVPs was significantly larger in patients with mitral annular disjunction than patients without mitral annular disjunction. Further investigation is needed to clarify the clinical significance of the mitral annular disjunction detected by routine echocardiography.
48 citations
TL;DR: VFM provided fairly accurate two-dimensional-flow information on cardio-hemodynamics and provided the basis for VFM-based diagnosis, according to these findings on VFM accuracy.
Abstract: The accuracy of vector flow mapping (VFM) was investigated in comparison to stereo particle image velocimetry (stereo-PIV) measurements using a left ventricular phantom. VFM is an echocardiographic approach to visualizing two-dimensional flow dynamics by estimating the azimuthal component of flow from the mass-conservation equation. VFM provides means of visualizing cardiac flow, but there has not been a study that compared the flow estimated by VFM to the flow data acquired by other methods. A reproducible three-dimensional cardiac blood flow was created in an optically and acoustically transparent left-ventricle phantom, that allowed color-flow mapping (CFM) data and stereo-PIV to be simultaneously acquired on the same plane. A VFM algorithm was applied to the CFM data, and the resulting VFM estimation and stereo-PIV data were compared to evaluate the accuracy of VFM. The velocity fields acquired by VFM and stereo-PIV were in excellent agreement in terms of the principle flow features and time-course transitions of the main vortex characteristics, i.e., the overall correlation of VFM and PIV vectors was R = 0.87 (p < 0.0001). The accuracy of VFM was suggested to be influenced by both CFM signal resolution and the three-dimensional flow, which violated the algorithm’s assumption of planar flow. Statistical analysis of the vectors revealed a standard deviation of discrepancy averaging at 4.5% over the CFM velocity range for one cardiac cycle, and that value fluctuated up to 10% depending on the phase of the cardiac cycle. VFM provided fairly accurate two-dimensional-flow information on cardio-hemodynamics. These findings on VFM accuracy provide the basis for VFM-based diagnosis.
33 citations
TL;DR: LA strain determined by 3D-STE is a novel and better predictor of AF recurrence after CA than that determined by 2D- STE or other known predictors.
Abstract: Several studies have shown the utility of left atrial (LA) function determined by two-dimensional or three-dimensional speckle tracking echocardiography (2D- or 3D-STE) for identifying patients with paroxysmal atrial fibrillation (AF). However, whether 3D-STE is applicable for prediction of the recurrence of AF after catheter ablation (CA) remains unknown. We examined whether any 3D-STE parameters are better than 2D-STE parameters for the prediction of AF recurrence. Forty-two patients with paroxysmal AF (58 ± 10 years old, 69% male) underwent 2D- and 3D-STE within 3 days before first-time CA. The global peak LA longitudinal, circumferential, and area strains during systole (3D-GLSs, -GCSs, and -GASs, respectively) and those just before atrial contraction (3D-GLSa, -GCSa, and -GASa, respectively) were determined by 3D-STE and standard deviations of times to peaks of regional LA strains were calculated as indices of LA dyssynchrony. In 2D-STE, global LA longitudinal strains during systole and just before atrial contraction (2D-GLSs and -GLSa) were determined. During follow-up of 441 ± 221 days, 12 patients (29%) had AF recurrence. In the univariate Cox proportional hazard analysis, age [hazard ratio (HR): 1.08, p = 0.04], 3D-GCSs (HR: 0.91, p = 0.03), and 3D-GASs (HR: 0.95, p = 0.01) were predictors of AF recurrence, though associations of recurrence with 2D-STE parameters, indices of LA synchrony, and LA volume were not significant. Multivariable analysis showed that 3D-GASs was an independent predictor of AF recurrence (HR: 0.96, p = 0.048). LA strain determined by 3D-STE is a novel and better predictor of AF recurrence after CA than that determined by 2D-STE or other known predictors.
21 citations
TL;DR: Two-dimensional speckle tracking echocardiography (2D-STE) is useful and highly reproducible in assessing right heart function in AF patients and was predictive of sinus rhythm maintenance for up to 1 year.
Abstract: Background
Atrial fibrillation (AF) is a bi-atrial disease yet little attention has been given to right heart function in AF. We propose that the assessment of right atrial (RA) and right ventricular function (RV) using two-dimensional speckle tracking echocardiography (2D-STE) could be valuable in predicting AF recurrence in patients with paroxysmal AF (PAF).
19 citations
TL;DR: Transthoracic coronary flow detection by echo Doppler contributes to the assessment of the coronary reperfusion status in the emergency room for patients with ACS, prior to invasive coronary angiography.
Abstract: Echo Doppler is widely available in the clinical setting, and the feasibility of coronary flow detection in the left anterior descending coronary artery has been reported as >90% with the use of a high-frequency transducer. Coronary flow detection takes only a few minutes by skilled echocardiologists, and this noninvasive technique can provide useful physiological information in patients with various types of coronary artery disease. Coronary flow velocity reserve measurement by echo Doppler is a simple and easy technique. It is available in the echo laboratory as well as in the outpatient clinic, and can be used as an alternative examination to screen for significant coronary stenosis in patients with stable angina. Moreover, physiological information provided by coronary flow velocity reserve can be used in combination with other imaging modalities that can provide anatomical information of the coronary arteries such as coronary computed tomography or coronary angiography. Coronary flow velocity in patients with acute coronary syndrome (ACS) enables rapid noninvasive differentiation of TIMI-III from TIMI-II coronary reperfusion before emergency coronary intervention. Transthoracic coronary flow detection by echo Doppler contributes to the assessment of the coronary reperfusion status in the emergency room for patients with ACS, prior to invasive coronary angiography.
13 citations
TL;DR: Fetal echocardiography can effectively identify abnormal hearts and has enhanced prenatal detection of CHD and the concern in the Indian scenario is the late referrals, lack of follow-up, and financial difficulties, all of which conspire against the chance of the fetus with heart disease getting appropriate treatment.
Abstract: Fetal echocardiography is a complete two-dimensional and Doppler ultrasound evaluation of the human fetal cardiovascular system. It is completely noninvasive, harmless, and also serves as the fetal electrocardiogram. To analyze the fetal echocardiographic cases referred to a tertiary cardiac center. A total of 478 cases of fetal echocardiograms performed over a period of 5.5 years were compiled and analyzed. Details regarding gestational age, maternal, family history, exposure to teratogens, and reason for referral were recorded. The average gestational age at referral was 24.8 ± 4.6 weeks and maternal age was 24.7 ± 4.3 years. Indications for referrals were abnormal fetal cardiac scan in 128 (26.8 %), previous sibling with congenital heart disease (CHD) in 99 (20.7 %), maternal indications in 87 (18.2 %), echogenic intracardiac focus (EIF) in 87 (18.2 %), high risk in 50 (10.5 %), rhythm problems in 21 (4.4 %), and others (extracardiac malformations) in 6 (1.2 %). In the 87 CHD cases diagnosed, nearly 70 % had complex CHD and 66.7 % were referred only after 22 weeks of gestation. A further 103 cases had EIF, 17 cases had fetal arrhythmia, 3 cases had cardiac masses, and the remaining 268 cases had normal fetal echocardiograms. Fetal echocardiography can effectively identify abnormal hearts and has enhanced prenatal detection of CHD. The concern in the Indian scenario is the late referrals, lack of follow-up, and financial difficulties, all of which conspire against the chance of the fetus with heart disease getting appropriate treatment.
13 citations
TL;DR: These results confirm that RT3DE has good accuracy in everyday clinical practice and can be of clinical utility in all types of cardiomyopathy independently of LV geometric pattern, LV diameter or wall thickness, taking into account a slight underestimation of LV volumes and EF compared to MRI.
Abstract: Accurate quantification of left ventricular (LV) volumes [end-diastolic volume (EDV) and end-systolic volume (ESV)] and ejection fraction (EF) is of critical importance. The development of real-time three-dimensional echocardiography (RT3DE) has shown better correlation than two-dimensional (2D) echocardiography with magnetic resonance imaging (MRI) measurements. The aim of our study was to assess the accuracy of RT3DE and 64-slice computed tomography (CT) in the evaluation of LV volumes and function using MRI as the reference standard in a real-world population with various types of heart disease with different chamber geometry. The study population consisted of 66 patients referred for cardiac MRI for various pathologies. All patients underwent cardiac MRI, and RT3DE and 64 slices CT were then performed on a subsequent day. The study population was then divided into 5 clinical groups depending on the underlying heart disease. RT3DE volumes correlated well with MRI values (R
2 values: 0.90 for EDV and 0.94 for ESV). RT3DE measurements of EF correlated well with MRI values (R
2 = 0.86). RT3DE measurements resulted in slightly underestimated values of both EDV and ESV, as reflected by biases of −9.18 and −4.50 mL, respectively. Comparison of RT3DE and MRI in various types of cardiomyopathies showed no statistical difference between different LV geometrical patterns. These results confirm that RT3DE has good accuracy in everyday clinical practice and can be of clinical utility in all types of cardiomyopathy independently of LV geometric pattern, LV diameter or wall thickness, taking into account a slight underestimation of LV volumes and EF compared to MRI.
11 citations
TL;DR: This review attempts to summarize and discuss current studies in diastolic stress echocardiography to evaluate diastsolic dysfunction during exercise.
Abstract: Evaluation of diastolic dysfunction and diagnosis of heart failure with preserved ejection fraction (HFpEF) by echocardiography are routinely performed at rest. However, many patients with modest HFpEF develop symptoms such as dyspnea only during exercise. Therefore, echocardiographic analysis at rest could be insufficient to identify these patients. Recent studies have demonstrated the utility of diastolic stress echocardiography to evaluate diastolic dysfunction during exercise. This review attempts to summarize and discuss current studies in diastolic stress echocardiography.
10 citations
TL;DR: A comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in the authors' hospital are made.
Abstract: In this review, we make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in our hospital. The main objective of performing exercise stress echocardiography in patients with HCM is to evaluate left ventricular outflow tract obstruction, mitral regurgitation, left ventricular asynergy, and diastolic function during exercise. There are limitations to the explanations that can be provided for exertional symptoms when resting echocardiography is performed in patients with HCM. In contrast, exercise stress echocardiography causes the manifestation of findings that are latent at rest, which possibly provides the elucidation of symptom etiology. In this article, we focus on the usefulness of exercise stress echocardiography in HCM.
9 citations
TL;DR: The performance of an adequate Valsalva maneuver and the correct interpretation of its effect are described.
Abstract: The Valsalva maneuver is an easily performed maneuver with an interesting hemodynamic effect which can be used to aid accurate echocardiographic diagnosis. However, correct adequate performance is often missed. Here, we aim to describe the performance of an adequate Valsalva maneuver and the correct interpretation of its effect. The Valsalva hemodynamic effect consists of four basic phases which can be used in echocardiography to yield an accurate diagnosis. Valsalva is used to decrease preload and provoke left ventricular outflow tract (LVOT) gradient in dynamic LVOT obstruction. In addition, a decrease in E/A ratio in mitral inflow >50 % with Valsalva correlates with increased LV filling pressure and diastolic dysfunction. Valsalva also momentarily increases RA pressure and helps to unmask a patent foramen ovale with the use of saline contrast.
7 citations
TL;DR: Exercise LVESVi might be an independent predictor of prognosis in patients with asymptomatic moderate or severe AR, and was significantly associated with the clinical outcomes.
Abstract: Surgical timing of chronic aortic regurgitation (AR) remains a matter of debate because of limited data. This study assessed the prognostic value of exercise echocardiography in asymptomatic AR. This prospective study included 60 consecutive asymptomatic patients with isolated moderate or severe AR (mean regurgitant volume 56.7 ± 11.8 ml) and preserved ejection fraction who underwent exercise echocardiography. The clinical outcomes were defined by the presence of major adverse cardiovascular events (MACE) and the indication for aortic valve replacement (AVR) with class I or IIa classification in the current guidelines. During the average follow-up of 731 days, 12 patients suffered from the clinical events, including two patients developing MACE (3%) and ten patients indicating for AVR (17%). No difference in left ventricular (LV) ejection fraction at rest was found between the patients with and without the clinical events. The indexed LV diameters and LV volumes were significantly dilated in the patients with the clinical events. The Cox proportional hazards regression analysis resulted that the exercise LV end-systolic volume index (LVESVi) was significantly associated with the clinical outcomes [hazard ratio, 1.116; 95% CI (1.032–1.205); p = 0.006]. The Kaplan–Meier analysis showed that exercise LVESVi was clearly stratified the event-free survival. Exercise LVESVi might be an independent predictor of prognosis in patients with asymptomatic moderate or severe AR.
TL;DR: Whilst in clinical practice TTE performs well in identification of normal versus abnormal systolic function, it has substantial limitations across grades of dysfunction and in the assessment of LV size and mass.
Abstract: We evaluated the ability of transthoracic echocardiography (TTE) to correctly identify abnormal left ventricular (LV) size, function, and mass when compared to cardiac magnetic resonance (CMR). Whilst numerous studies have compared TTE and CMR with respect to correlation between measurements and study reproducibility, few have employed categorical analysis relevant to clinical practice. Two hundred and fifteen consecutive patients who underwent both TTE and CMR were evaluated for the presence of abnormal LV size, systolic function, and mass. Abnormal LV systolic function was further categorized into grades (mild, moderate, and severe). Quantification of LV morphology and function was performed on TTE and CMR according to published guidelines. The level of agreement between TTE and CMR was compared across binary and categorical variables using Cohen’s kappa. Compared to CMR, TTE demonstrated excellent agreement in identification of abnormal versus normal function (κ = 0.87). However, agreement across grades of LV function was less strong (κ = 0.63). Whilst agreement for identification of severe LV dysfunction was good (κ = 0.68), this would still lead to misclassification of severe dysfunction in approximately one in seven cases. Agreement between TTE and CMR was moderate to good for identification of LV dilation (κ = 0.43–0.63), but poor for identification of increased mass (κ = 0.04). Whilst in clinical practice TTE performs well in identification of normal versus abnormal systolic function, it has substantial limitations across grades of dysfunction and in the assessment of LV size and mass. These limitations have important implications when considering management decisions for patients based on thresholds of LV morphology or function.
TL;DR: Selenium deficiency and combined RVSD and pulmonary hypertension seemed to be the only determinants of RVDD in this small cohort, a finding that needs verification in a larger sample of patients.
Abstract: BACKGROUND: This study aimed to assess the prevalence of right ventricular diastolic dysfunction (RVDD) and its potential predictors in peripartum cardiomyopathy (PPCM) patients.METHODS: This was a ...
TL;DR: The topic of the flow pattern inside the heart and vortex imaging has been a main stream of research in echocardiography during the past decade and knowledge gained about LV fluid dynamics, and in particular the associated vortical flow motion, has introduced novel clinical indicators for LV function based on vortex dynamics.
Abstract: ‘‘Begin challenging your own assumptions. Your assumptions are your windows on the world. Scrub them off every once in a while, or the light will not come in.’’—Alan Alda [1]. The topic of the flow pattern inside the heart and vortex imaging has been a main stream of research in echocardiography during the past decade. Progress has been made to incorporate quantitative fluid dynamics into echocardiography using particle tracking algorithms [2, 3, 39] that are based mostly on the well-known optical imaging techniques of particle image velocimetry (PIV) [4–6] or color Doppler imaging [7–10]. Recent advances in understanding left ventricular (LV) fluid dynamics based on experimental methods [11–14] and numerical simulations [15–17] have shed light on many aspects of ventricular flow, such as the development of intraventricular vortices. These vortices are shown to significantly influence transmitral momentum transfer and help redirect the flow from the left atrium toward the left ventricular outflow tract (LVOT) [18, 19]. Alternatively, formation of unnatural vortices can be a sign of adverse blood flow, which may indicate progressive LV dysfunction [18–21]. The knowledge gained about LV fluid dynamics, and in particular the associated vortical flow motion, has introduced novel clinical indicators for LV function based on vortex dynamics [18, 19, 21–25]. PIV is an optical method for flow visualization used to obtain instantaneous velocity measurements and related properties in the fluids. In this technique, the fluid is seeded with tracer particles, which are assumed to faithfully follow the dynamics of flow. The motion of these seeding particles is used to compute the flow velocity. In its current form, 2D ultrasound-based PIV or 2D echocardiographic PIV (EchoPIV) was introduced by Kim et al. [2], through capturing digital B-mode images of contrast agent particles, and further used for vortex imaging by Kheradvar et al. [21]. This technique computes the velocities of the ultrasoundimaged particles based on the PIV technique, with the Dt being equal to scanning time. The number of beams and the samples along each beam define the number of pixels for each image after scan conversion. Particles used as the flow tracers are microbubbles filled with octafluoropropane encapsulated in either a lipid (DEFINITY , Lantheus Medical Imaging, Inc.) or protein (Optison, GE Healthcare) outer shell [3, 26], which are both FDA-approved for clinical use. This technique allows the velocity directions and streamlines, principal blood flow patterns, recirculation regions, and vortices to be drawn with reasonable confidence in a reproducible scheme [18, 21, 22, 27–32]. Alternatively, vector flow mapping (VFM) measures blood flow velocity by considering color Doppler imaging and ventricular wall velocity [7–10]. This method works based on combining measured axial velocities with estimated radial velocities according to the physical principles [33]. VFM ignores the three-dimensional component of the flow by assuming the flow is two-dimensional, solves the 2D continuity equation, and use ventricular wall velocity acquired by tissue tracking to improve the results [34]. & Arash Kheradvar arashkh@uci.edu
TL;DR: Patients with Chagas disease have no abnormalities in torsional mechanics during its indeterminate and initial cardiomyopathy stages.
Abstract: Chagas disease (CD) is highly endemic in Latin America, and has been emerging in developed countries. Early diagnosis of left ventricular (LV) systolic dysfunction, routinely done by echocardiography, is crucial for therapy. Speckle tracking echocardiography allows determination of LV segmental rotations, twist/torsion, and this analysis may disclose an unapparent myocardial contractile deficit in initial stages of CD. Therefore, this study aimed to highlight a possible unapparent myocardial contractile deficit in CD indeterminate form (IF) by a comprehensive torsional mechanics analysis. Patients with CDIF diagnosis, initial chagasic cardiomyopathy (CCMP characterized by ECG abnormalities and LVEF > 0.55), and normal controls were prospectively enrolled, and underwent conventional echocardiogram with images acquisition for STE offline analysis. Target parameters were basal and apical rotations, and calculation of twist and torsion. A total of 42 patients were included (CDIF, eight; CCMP, 13; and 21 controls). Chagasic patients had a mean age of 55 years, five (24 %) men, and controls, 50 years, seven (33 %) men. Torsional mechanics analyzes resulted in no significant difference in all parameters studied between groups. Twist in CDIF was 20.8° ± 6.5°; CCMP, 19.0° ± 3.5° and controls, 19.7° ± 3.7° (p = 0.67). Torsion in CDIF was 2.6° ± 0.8°; CCMP, 2.4° ± 0.6° and controls, 2.4° ± 0.5° (p = 0.63). Patients with Chagas disease have no abnormalities in torsional mechanics during its indeterminate and initial cardiomyopathy stages.
TL;DR: RDN reduced blood pressure and significantly improved functional myocardial parameters such as A-wave velocity and peak untwisting velocity in patients with treatment-resistant hypertension, suggesting a potential beneficial effect of RDN on myocardIAL mechanics.
Abstract: Background: Speckle tracking echocardiography (STE) is an echocardiography modality that is able to measure left ventricular (LV) characteristics, including rotation, strain and strain rate. Strain measures myocardial fibre contraction and relaxation. This study aims to assess the effect of renal sympathetic denervation (RDN) on functional myocardial parameters, including STE, and to identify potential differences between responders and non-responders.
Methods: The study population consisted of 31 consecutive patients undergoing RDN in the context of treatment for resistant hypertension. Patients were included between December 2012 and June 2014. Transthoracic echocardiography and speckle tracking analysis was performed at baseline and at 6 months follow-up.
Results: The study population consisted of 31 patients with treatment-resistant hypertension treated with RDN (mean age 64 ± 10 years, 15 men). The total study population could be divided into responders (n = 19) and non-responders (n = 12) following RDN. RDN reduced office blood pressure by 18.9 ± 26.8/8.5 ± 13.5 mmHg (p < 0.001). A significant decrease was seen in LV posterior wall thickness (LVPWd) (0.47 ± 1.0 mm; p = 0.020), without a significant change in the LV mass index (LVMI). In the total cohort, only peak late diastolic filling velocity (A-wave velocity) decreased significantly by 5.3 ± 13.2 cm/s (p = 0.044) and peak untwisting velocity decreased significantly by 14.5 ± 28.9°/s (p = 0.025).
Conclusion: RDN reduced blood pressure and significantly improved functional myocardial parameters such as A-wave velocity and peak untwisting velocity in patients with treatment-resistant hypertension, suggesting a potential beneficial effect of RDN on myocardial mechanics.
TL;DR: The PVA might be a useful method for diagnosis of type-B AD, when adequate images of the DTA are obtained, and whenadequ images of DTA were obtained using the PVA, 80.9% of the patients were diagnosed with type- B AD.
Abstract: Transthoracic echocardiography (TTE) is not recommended as the first-line diagnostic modality for Stanford type B aortic dissection (type-B AD). The aims of this study were to evaluate the usefulness and factors influencing for the diagnosis of type-B AD using the transthoracic echocardiographic paravertebral approach (PVA). We compared the image acquisition rate of descending thoracic aorta (DTA) and the diagnostic rate of type-B AD using TTE versus PVA. Both tests were compared with type-B AD, which was diagnosed by enhanced computed tomography (CT), as the reference standard. We also analyzed the factors influencing adequate image acquisition and the diagnosis of type-B AD using the PVA. The length between the dorsal thoracic surface and the DTA (TDAL) and thickness of lung on the TDAL line (LTh) were measured on the CT images. No significant difference was found between the image acquisition rate of the DTA between the PVA and the TTE (70.1 vs. 64.2%, p = 0.56), while the diagnostic rate of type-B AD using the PVA was significantly greater than when using the TTE (56.7 vs. 26.9%, p < 0.001). Furthermore, when adequate images of DTA were obtained using the PVA, 80.9% of the patients were diagnosed with type-B AD. A multivariate analysis demonstrated that a lower LTh (p = 0.001) and the existence of a pleural effusion (p = 0.03) significantly influenced the diagnosis of type-B AD using the PVA. The PVA might be a useful method for diagnosis of type-B AD, when adequate images of the DTA are obtained.
TL;DR: A simulation-based curriculum to teach transesophageal echocardiography (TEE) to first-year cardiology fellows was created and the change in their reported self-confidence in TEE skills was measured.
Abstract: Cardiology fellows learn procedures by performing them on patients under faculty supervision. Such training may increase procedure times, compromise image quality, and cause complications. Simulators provide an opportunity to teach procedures where patients are not at risk. We created a simulation-based curriculum to teach transesophageal echocardiography (TEE) to first-year cardiology fellows and measured the change in their reported self-confidence in TEE skills.
TL;DR: TAPSE is a simple predictor of the effectiveness of tolvaptan in patients with HF and the area under the curve of TAPSE was the largest among the parameters measured by echocardiography.
Abstract: There is no echocardiographic predictor of the effectiveness of tolvaptan in patients with heart failure (HF). The aim of this study was to investigate the echocardiographic predictor of responders to tolvaptan in patients with HF. This observational study consisted of 62 consecutive in-hospital patients with HF who received tolvaptan with volume overload despite standard therapies. The echocardiography data were obtained within 1 week before the administration of tolvaptan. Tolvaptan responders were defined as those having a body weight decrease from baseline >1 kg on the morning of day 8. The mean age of the 62 patients was 75.1 ± 13.9 years, and 45 patients (72.6%) were considered to be responders. Tricuspid annular plane systolic excursion (TAPSE) was significantly higher (17.1 ± 3.8 vs. 13.0 ± 3.9 mm; p = 0.0004) and the tricuspid valve regurgitation pressure gradient (33.3 ± 14.6 vs. 44.9 ± 12.2 mmHg; p = 0.007) and estimated right atrium pressure (7.8 ± 4.2 vs. 10.3 ± 4.5 mmHg; p = 0.043) were significantly lower in the Responder group than in the Non-responder group. In a multivariate logistic regression analysis, TAPSE was found to be an independent predictor of response (odds ratio 1.28; 95% confidence interval 1.03–1.60). According to the receiver operating characteristics analysis, the area under the curve of TAPSE was the largest among the parameters measured by echocardiography. The cut-off value for TAPSE to predict responders was determined to be 17.0 mm (sensitivity = 56.8%, specificity = 94.1%). TAPSE is a simple predictor of the effectiveness of tolvaptan in patients with HF.
TL;DR: A 77-year-old female patient with a history of chronic obstructive pulmonary disease and paroxysmal atrial fibrillation presented to the emergency department with collapse and was diagnosed with sick sinus syndrome and successfully implanted a DDD-R pacemaker without any acute complications.
Abstract: A 77-year-old female patient with a history of chronic obstructive pulmonary disease and paroxysmal atrial fibrillation presented to our emergency department with collapse and was diagnosed with sick sinus syndrome. Before pacemaker implantation, echocardiography showed normal dimensions of both atria and ventricles and normal systolic left and right ventricle (RV) function. A DDD-R pacemaker was successfully implanted using active-fixation leads without any acute complications. The day after implantation, sensing and pacing parameters were normal and unchanged. Chest radiography then showed a normal position of both leads (Fig. 1a, b). Subsequently, the patient was discharged the same day in good clinical health. Four days later, however, the patient was readmitted because of sharp chest pain, unrelated to physical activity or posture. Pacemaker data showed a marked switch from bipolar to unipolar lead pacing and malcapture of the RV lead at maximal pacemaker output. Chest radiography revealed an altered RV lead position (Fig. 1c, d). Echocardiography suggested a perforation of the RV lead through the RV apex but without pericardial effusion (Fig. 1e and online video). This raised doubt as to whether the lead tip lay in the pericardial space. Ultimately, thoracic computed tomography (CT) showed that the lead went through the myocardium (Fig. 1f, g). The patient was subsequently transferred to a specialized pacing lead extraction center with surgical backup, where the RV lead was repositioned uneventfully.
TL;DR: 3D color Doppler TUI displayed the inflow streams of the LV and RV simultaneously and separately, which assisted in understanding the spatial relationship of the atrioventricular connections and suggested a prenatal diagnosis of criss-cross heart with mitral stenosis, hypoplasia of theLV, VSD, DORV, and CoA.
Abstract: A 23-year-old woman was referred to us at 33 weeks of gestation because of an abnormal fetal four-chamber view. Fetal echocardiography showed that the right atrium, tricuspid valve, right ventricle (RV), pulmonary valve and pulmonary artery were on the same axial plane of the chest (Fig. 1a, Video 1a). The left atrium (LA) seemed normal, but the left ventricle (LV) was not depicted. The ventriculoarterial connection was suspected to be a double outlet right ventricle (DORV) with coarctation of the aorta (CoA). At 34 weeks, a small LV was depicted more inferiorly to the RV on the sagittal plane of the chest (Fig. 1b, Video 1b). A detailed observation of the LV revealed that the LA was connected to the inferior small LV on the right side through a restricted mitral valve (Fig. 1c, Video 1c). A ventricular septal defect (VSD) was also detected. Threedimensional (3D) color Doppler tomographic ultrasound imaging (TUI) (Voluson E8; GE Healthcare Japan, Tokyo, Japan) revealed that the inflow of the LV, which ran from left to right, was inferior to the inflow of the RV, which ran from right to left (Fig. 1d, Video 1d). Furthermore, 3D color Doppler rendering imaging clearly showed the crossing of the inflow streams of the RV and LV up and down (Fig. 1e, Video 1e). These findings suggested a prenatal diagnosis of criss-cross heart with mitral stenosis, hypoplasia of the LV, VSD, DORV, and CoA. The prenatal diagnosis was confirmed by neonatal echocardiography that revealed the perimembranous VSD (10.8 mm) as well as the presence of a secundum atrial septal defect (8.2 mm). Criss-cross heart is a rare complex congenital cardiac malformation characterized by crossing of the inflow streams of the ventricles due to twisting of the heart along its long axis [1]. Only a few prenatally diagnosed cases have been reported previously [2–4]. 3D color Doppler TUI displayed the inflow streams of the LV and RV simultaneously and separately, which assisted us in understanding the spatial relationship of the atrioventricular connections. Moreover, 3D color Doppler rendering imaging clearly delineated the characteristic crossing of the inflow streams; these are difficult to see with 2D color Doppler because the two AV valves are not visualized on the same plane due to the twisting of the heart [1]. Although 3D echocardiography has been implemented, 2D echocardiography is the principal tool for evaluating fetal heart defects [5]. One of the main reasons for this is that the image resolution obtained with a 3D dataset is not as good as that of 2D real-time ultrasound. In this case, 2D echocardiography visualized each atrioventricular inflow tract clearly, but the 2D images required us to create a mental 3D reconstruction of the complexed atrioventricular connections for the diagnosis of criss-cross heart. Electronic supplementary material The online version of this article (doi:10.1007/s12574-017-0339-3) contains supplementary material, which is available to authorized users.
TL;DR: A rare case of a P-MAIVF, where no etiology was found and the lesion had not produced any symptoms in a young child is described.
Abstract: Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a condition that has been reported in adults as a sequela of infective endocarditis, aortic surgery, and trauma [1–3]. However, in pediatric patients, this condition is extremely rare. Morphologically, it is a false aneurysm at the fibrous, interannular zone, between the mitral and aortic valves. It communicates with the left ventricular outflow tract (LVOT) between the anterior leaflet of the mitral valve and the left coronary or non-coronary cusp of the aortic valve [1]. In adults, this is an acquired finding, however, here we describe a rare case of a P-MAIVF, where no etiology was found and the lesion had not produced any symptoms in a young child.
TL;DR: An 88-year-old woman referred to the authors' hospital because of complete atrioventricular block was diagnosed with a perforation of an LV pseudo-false aneurysm into the RV following the subacute phase of an inferior MI, and died 10 days after admission as a result of multi-organ failure.
Abstract: We describe a case of left ventricular (LV) pseudo-false aneurysm perforating the right ventricle (RV), which is a very uncommon complication of myocardial infarction (MI). An 88-year-old woman was referred to our hospital because of complete atrioventricular block. She was drowsy, her heart rate was 27 beats/min, and her blood pressure was 90/70 mmHg. A grade of II/VI pansystolic murmur was audible at the lower sternal border. Echocardiographic study revealed an aneurysm on the inferoseptum and a large (30 mm) defect between the inferoseptal wall and the aneurysm (Fig. 1a). A color Doppler image showed shunt flows passing from a large defect of inferoseptal myocardium and the aneurysmal pouch to the RV (Fig. 1b, c). Coronary arteriography was performed and the proximal right coronary artery (RCA) was occluded. The left coronary arteries were normal and percutaneous coronary intervention of the RCA was not performed. On the basis of the initial laboratory examination findings (creatine kinase 563 U/L, creatine kinase MB 29.1 ng/mL, troponin I 49.31 ng/mL), she was diagnosed with a perforation of an LV pseudo-false aneurysm into the RV following the subacute phase of an inferior MI. Temporary pacing and intra-aortic balloon pumping were started, and prompt surgical repair of the LV pseudo-false aneurysm was considered. However, her operative risk was high and her family desired conservative management. She died 10 days after admission as a result of multi-organ failure. An LV pseudo-false aneurysm, which was first reported by Stewart et al. [1], is a very uncommon complication of MI. It occurs when hemorrhagic dissection into the area of a transmural MI does not completely reach the epicardium and is contained within the area of the infarcted myocardium. Several authors described the perforation of an LV pseudo-false aneurysm into the RV following acute inferior MI [2, 3]. Although the hemodynamics of this condition are similar to those of postinfarction ventricular septal defect, the perforation usually develops in the subacute or chronic phase of MI. Although no pathology examination was performed, the present patient was diagnosed as having an LV pseudo-false aneurysm on the basis of echocardiographic findings of incompletely dissected myocardium and the aneurysmal pouch containing the area
TL;DR: A vigilant examination and the simple tool of agitated saline helped us in defining anatomy and ruling out a septal defect in a 70-year-old male patient with new-onset atrial fibrillation and heart failure.
Abstract: A 70-year-old male patient was admitted to our hospital with new-onset atrial fibrillation and heart failure. Transthoracic echocardiogram demonstrated rheumatic mitral stenosis (Fig. 1). Transesophageal echocardiogram (TEE) performed for preoperative evaluation of mitral valve apparatus confirmed the diagnosis of severe mitral stenosis. Standard images of the right atrium showed a possible ostium secundum atrial septal defect (ASD). Color Doppler showed flow across the presumed defect, thus excluding a dropout artifact. However, on astute assessment with multiple views, the true atrial septum was visualized, and it was the space between a prominent Eustachian valve (EV) and the atrial septum that gave a false impression of a defect. This was confirmed with agitated saline contrast, which showed no flow across the true atrial septum (Fig. 2). The Eustachian valve is an embryologic remnant of the valve of the inferior vena cava (IVC), manifested as a crescentic fold of endocardium arising from the anterior rim of the IVC orifice [1, 2]. There is a large variety in size, shape, and thickness of persistent Eustachian valves and it is important to know the variants in assessing the right atrium. There are cases where Eustachian valves have been mistaken for vegetation, mass, thrombus, cor triatriatum, and inappropriate interventions have been performed [3–5]. In our case, the Eustachian valve gave a pseudo atrial septal defect. The elevated left atrial pressure secondary to mitral stenosis may have caused the atrial septum to be pushed more towards the Eustachian valve. A vigilant examination and the simple tool of agitated saline helped us in defining anatomy and ruling out a septal defect (Supplementary Video. 1).
TL;DR: An 88-year-old man presented to the emergency room with dyspnea and lower extremity swelling over 2 weeks and Diffuse large B-cell lymphoma was confirmed on tissue biopsy of an associated neck lymphadenopathy.
Abstract: An 88-year-old man presented to the emergency room with dyspnea and lower extremity swelling over 2 weeks. Physical examination was remarkable for a heart rate of 110 beats per minute and blood pressure of 86/50 mmHg. He also had elevated jugular venous pressure, distant heart sounds, lower extremity edema, and a pulsus paradoxus of 12 mmHg. Emergent echocardiography showed a large pericardial effusion with evidence of right atrial and ventricular collapse. Pericardiocentesis removed 600 ml of bloody fluid with negative cultures and cytology. A computed tomography (CT) scan of the chest and abdomen performed to rule out underlying malignancy was unremarkable. The patient was readmitted 2 months thereafter with recurrent dyspnea. Repeat echocardiogram showed a small to moderate pericardial effusion in addition to a 3.5 9 3.6cm mass at the atrioventricular (AV) groove in close proximity to the tricuspid valve annulus that appeared to have an echogenic center (Fig. 1a, b). Repeat CT scan of the chest showed a mass encasing the right coronary artery without apparent coronary artery stenosis (Fig. 1c). Diffuse large B-cell lymphoma (DLBCL) was confirmed on tissue biopsy of an associated neck lymphadenopathy. Given the patient’s age and co-morbidities, he was eventually transitioned to hospice care.
TL;DR: This is the first case description of an ARAT draining into a right atrial pedunculated mass and demonstrates the importance of multi-modality imaging in investigating these structures, which are a rare congenital anomaly of which the embryology and etiology remain unclear.
Abstract: A 25-year-old female was referred for echocardiography due to cardiomegaly noted on a chest X-ray after an uneventful delivery. The patient was asymptomatic and the clinical examination was unremarkable. Transthoracic echocardiography showed a ‘snake-like’ structure extending from the aortic root posterior to the left atrium (Fig. 1a, Supplementary Data 1) with continuous systolic and diastolic flow on Doppler (Fig. 1b). A transesophageal echocardiogram showed a dilated left sinus of Valsalva and a ‘tunnel’ posterior to the aorta. A pedunculated right atrial mass measuring 2.5 9 3.7 cm was also noted (Fig. 1c, Supplementary Data 2). On invasive coronary angiography, the aneurysmal sinus gave off normal caliber left anterior descending and circumflex arteries and extended as a giant tunnel towards the right (Fig. 1d, Supplemental Data 3). 64-slice ECG-gated multidetector computed tomography (MDCT) (Fig. 1e, Supplementary Data 4) revealed that the tunnel took a course posterior to the ascending aorta and divided into two branches. The superior branch drained into the superior vena cava while the inferior branch drained into the right atrium at the level of a hypoattenuated right atrial mass; this was noted to enhance with contrast (Fig. 1f, Supplementary Data 5), demonstrating that the right atrial mass was a continuation of the tunnel. A left to right shunt of 1.2 was estimated. The patient refused intervention and has remained asymptomatic. Aorto-right atrial tunnels (ARATs) are a rare congenital anomaly of which the embryology and etiology remain unclear. Tunnels arising from all three sinuses of Valsalva and draining into the right atrium have been described [1]. This ARAT appeared to be draining into a right atrial mass, possibly a benign endocardial hemangioma. Hemangiomas make up 5–10% of primary intracardiac tumors, which have an incidence of 0.001–0.3% [2]. Gajjar et al., however, proposed that ARATs arise from a defective area in the aortic wall forming an extracardiac tunnel and rupturing into the right atrium because of anatomic proximity and low filling pressure [1]. Interestingly, a histological examination taken from one ARAT showed aortic tissue [3]. This explanation, however, fails to explain drainage via a suspected hemangioma as in our case. ARATs have also been associated with secundum-type atrial septal defects and patent ductus arteriosus. This is the first case description of an ARAT draining into a right atrial pedunculated mass and demonstrates the importance of multi-modality imaging in investigating these structures. Electronic supplementary material The online version of this article (doi:10.1007/s12574-017-0328-6) contains supplementary material, which is available to authorized users.
TL;DR: An unusual and unexpected echocardiography image resulting in unpredictable hemodynamic changes (the negative pressure during placement or removal of the left atrial vent or during deairing manoeuvres, or) is presented.
Abstract: The inverted left atrial appendage (LAA) is a rare cause of a left atrial mass and often leads to misdiagnoses [1, 2], and the natural history and incidence of subsequent complications are, as yet, undefined. When an inverted LAA is discovered postoperatively, it invariably presents as an echogenic, left atrial mass on transesophageal or transthoracic echocardiography. Differential diagnoses include atrial myxoma, vegetation, or thrombus, with the last being more likely in a patient immediately postsurgery [3]. We present the case of a 61-year-old male with a history of anterior left ventricle and infarction and depressed low ejection fraction (EF 0.20), who suffered from postischemic dilated cardiomyopathy. He was admitted for left ventricular assist device (LVAD) implantation in our department (INTERMACS Class 2). Preoperative transesophageal echocardiography (TEE) revealed a mild mitral valve regurgitation, dilated left atrium, and severe akinesia of extended left ventricle segments without endocardial thrombotic apposition, no atrial mass, and normal LAA shape (Fig. 1a, b). The patient underwent LVAD implantation (axial flow device) by standard cardiopulmonary bypass and through median sternotomy access. Postoperative transthoracic echocardiography revealed a long, large, and ellipsoidal hyperechoic image (18 9 14 mm) inside the left atrium, upper and nearer the mitral valve orifice. TEE confirmed the presence of the hyper echoic mass arising from the lateral left atrial wall (Fig. 1c) and fixed near the mitral annulus during cardiac diastole without signs of obstruction associated with increased flow velocity into the left superior pulmonary vein (Fig. 1d, e, Movie 1). Afterwards, we recognized that the cardiac structure was the left atrial appendage but inverted and mimicking a left atrial mass. We present an unusual and unexpected echocardiography image resulting in unpredictable hemodynamic changes (the negative pressure during placement or removal of the left atrial vent or during deairing manoeuvres, or
TL;DR: This research presents a novel, scalable, scalable and scalable approaches that allow for real-time, 3D image analysis of the response of the immune system to central nervous system transplants.
Abstract: Electronic supplementary material The online version of this article (doi: 10.1007/s12574-016-0299-z ) contains supplementary material, which is available to authorized users.
TL;DR: It is speculated that atrial cardiomyopathy induced by persistent inflammation of rheumatic fever and LA dysfunction may have caused the severe heart failure in this case.
Abstract: A 60-year-old man was admitted to our hospital with progressive heart failure. He had a medical history of mitral and aortic valve replacement with bioprosthesis for long-standing rheumatic heart disease. An electrocardiogram revealed atrial fibrillation. A chest X-ray revealed cardiomegaly, pulmonary congestion, and bilateral pleural effusion. A blood test showed a high plasma brain natriuretic peptide concentration of 336 pg/ml. Transthoracic echocardiography showed dilation of the left atrium (LA) (77 mm), and the estimated systolic pulmonary pressure was 66 mmHg with severe tricuspid regurgitation. The left ventricle (LV) end-diastolic dimension was 55 mm, and the LV ejection fraction was 61%. Evaluation of LA function by two-dimensional speckle tracking echocardiography showed a significant decrease in the LA systolic strain and strain rate (Fig. 1a). Cinefluoroscopy revealed normal bioprosthetic valve motion without leaflets dysfunction. Computed tomography confirmed the severity of LA dilation and massive calcification around the LA wall (Fig. 1b). Right-sided heart catheterization revealed pulmonary hypertension with a systolic pulmonary pressure (PAP) of 95 mmHg (mean PAP 42 mmHg), pulmonary artery wedge pressure of 41 mmHg, and a dip-and-plateau pattern of the right ventricular pressure. Despite undergoing intensive treatment, the patient died of progressive heart failure. Written informed consent for autopsy was provided by the patient’s next-of-kin. An autopsy showed marked calcification of the endocardial surface of the LA (Fig. 1c). Microscopic analysis revealed intensive calcification and fibrotic changes under the endocardial layer (Fig. 1d); however, no specific findings were detected in other organs. Massive calcification of the LA, called a ‘‘coconut atrium’’ or ‘‘porcelain atrium’’, is a rare complication in patients with rheumatic heart disease [1–3]. Calcification of the LA wall may decrease the reservoir and contractile function of the LA, leading to decreased cardiac output, increased LA pressure, persistent pulmonary hypertension, and right heart pressure overload [3], resulting in refractory heart failure. The pathogenesis of LA calcification with rheumatic valvular heart disease is unknown; however, long-term persistent LA inflammation caused by rheumatic fever may lead to the development of severe calcification [3]. Additionally, dysfunction of the endocardium induced by chronic pressure on the LA wall plays a significant role in LA calcification and long-term hemodynamic forces in the LA induce dysfunction of the endocardium, which may lead to severe calcification of the LA [1]. We speculate that atrial cardiomyopathy [4] induced by persistent inflammation of rheumatic fever and LA dysfunction may have caused the severe heart failure in this case.
TL;DR: Right-sided venous air embolism is a recognised complication of caesarean section, thought to generate within a contracting uterus following delivery, where air under pressure rarely enters uterine venous drainage, presenting as catastrophic cardiorespiratory decompensation with sudden hypotension and hypoxaemia.
Abstract: A 29-year-old woman in the 36th week of her first, uneventful pregnancy with no prior medical history underwent planned caesarean section delivery under epidural due to breech presentation. The operative procedure was uncomplicated. On wound closure, the patient suffered sudden haemodynamic collapse and then cardiac arrest. Following two cycles of cardiopulmonary resuscitation, spontaneous circulation was restored. There was no inordinate blood loss. Electrocardiogram (ECG), blood gas and subsequent bloods were normal. An ECG performed immediately after restitution of spontaneous circulation found microbubbles in the left atrium passing in an antegrade direction through the left ventricule to the aorta, with appearances suggestive of air embolus (see Fig. 1 and videos 1 and 2 in the supplementary material). Left ventricular function appeared normal. No intraatrial or intraventricular communication was seen. Intravenous access lines showed no evidence of iatrogenic air embolus. The echocardiogram was carried out prior to obtaining central venous access, excluding pulmonary trauma introducing systemic air emboli. Computed tomography pulmonary angiography excluded pulmonary embolus, with no evidence of pulmonary arteriovenous malformation. Computed tomography of the brain showed no cerebral air embolus. Following supportive treatment with high-flow oxygen, she was extubated the following day with no evident neurological sequelae. A repeat echocardiogram at 4 h demonstrated resolution of microbubbles. A transthoracic bubble study with Valsalva manoeuvre showed no communication from the right to left heart. Magnetic resonance imaging found a structurally normal heart, with normal biventricular function. No evidence of shunt or atrial septal defect was seen across studies. The source of the systemic microbubbles remains unclear, and their capture on echocardiogram is rare. Right-sided venous air embolism is a recognised complication of caesarean section, thought to generate within a contracting uterus following delivery, where air under pressure rarely enters uterine venous drainage, presenting as catastrophic cardiorespiratory decompensation with sudden hypotension and hypoxaemia [1, 2]. Transit of venous air emboli from venous to systemic circulation, as seen in this case, has been described via pulmonary arteriovenous (AV) fistula [3] and patent foramen ovale (PFO) [4] following caesarean section. A similar case report postulates that, in the absence of obvious shunt, massive uterine air embolisation may overwhelm the capacity of the lungs to filter air emboli, leading to transit via pulmonary capillaries to systemic circulation [5]. Alternatively, a small PFO may not be identifiable on baseline imaging, where it poses no significant functional consequences within normal physiological intracardiac flow, yet a massive haemodynamic insult may cause temporary right-to-left shunt. In the absence of supporting evidence of intracardiac shunt despite comprehensive assessment and investigation, a pulmonary AV shunt seems most likely. Electronic supplementary material The online version of this article (doi:10.1007/s12574-016-0318-0) contains supplementary material, which is available to authorized users.