Objectives: Echocardiographic assessment of Left ventricular systolic function is traditionally being performed by estimation of fractional shortening and Ejection fraction. Speckle tracking echocardiography (STE) is a promising tool for assessment of myocardial function. The aim of this study is to evaluate the global longitudinal strain (GLS) using 2D-STE in healthy neonates to establish normal reference ranges. Method: it is a retrospective study through an analysis of transthoracic echocardiogram of normal healthy neonates. We enrolled all neonates in our institution from 1 st January 2021 to 28 th February 2021. 2-D STE was used to assess left ventricular global longitudinal strain from the apical views. Results: 185 neonates were enrolled. Mean value for left ventricle GLS (%) was -19.9 ± 1.2, GLS-derived ejection fraction (%) was 60.0 ± 2.7; while the left ventricle ejection fraction by biplane Simpson’s method (%) was 61.0 ± 3. There is a good positive correlation between the Left Ventricle EF by biplane Simpson’s method and EF by 2-D STE, which was statistically significant ( r = 0.294, n = 102, p=0.003). Apical 4-chamber longitudinal strain and strain derived EF is significantly correlated with GLS and bi-plan EF respectively. Conclusion: 2-STE is feasible technique for analyzing newborn myocardial systolic function. The normal range of GLS in neonates is not much different than reported for the pediatric. There is a good positive correlation between the Left Ventricle EF by 2-D STE and EF by biplane method.
Background Two-dimensional (2D) strain imaging has become an important tool in assessing subclinical myocardial dysfunction in children. However, there are no pediatric reference values for vendor independent strain software. The aim of this study was to estimate 2D strain values in a cohort of healthy children using Tomtec cardiac performance analysis (CPA), a vendor independent software. Methods Transthoracic echocardiograms of healthy pediatric outpatients (0-18yrs) were retrospectively analyzed from the Vanderbilt Pediatric Heart Institute using CPA. Cardiac assessment included global longitudinal strain (GLS), global longitudinal strain rate (GLSR), global circumferential strain (GCS), global circumferential strain rate (GCSR). Mean strain values with standard deviation (SD) are reported. The Wilcoxon rank sum test, linear regression and one-way analysis of variance were used to assess differences among the various groups. Results Among 142 children analyzed, 79 (56%) were male, and the median age was 5.5 (range, 0-18) years. The mean (SD) strain values were GLS -19.3 ± 3.4, GLSR -1.1 ± 0.22; GCS -24.7 ± 4.3, GCSR -1.5 ± 0.28. Age accounted for <8% of variation in GLS, GCS and GSCR. However, for GLSR, there was a statistically significant difference between younger and older age groups with higher GLSR in the younger age group. Age accounted for ~25% of variation in GLSR (R 2 = 0.25, P < 0.001). There were no significant differences in strain based on sex. Conclusion We report normal reference values in healthy children by age for strain using CPA. These values are necessary for the interpretation of 2D strain imaging for both clinical care and research.
We read with great interest the article by Vetrugno et al. who reported the important association of preoperative diastolic dysfunction (DD) and early liver allograft dysfunction.(#ref-0001) We salute the authors on this detailed and important investigation, and would like to highlight several points. First, the authors provide the cohort analysis of donors’ and recipients’ demographic variables (Table 1, Ref(#ref-0001)), however statistical comparative analysis of the three study groups and these variables is absent. Moreover, additional, important demographic variables (e.g., ethnicity, presence of trans jugular intrahepatic portosystemic shunt; hepato-pulmonary syndrome, porto-pulmonary hypertension, pretransplant hospitalization or vasopressors; QT interval) and intraoperative variables (e.g., hemoglobin, coagulative and thromboelastographic parameters, arrhythmias, immunosuppression, and post-reperfusion syndrome and vasopressors) were not included in the groups’ analysis (Table 4, Ref(#ref-0001)). These parameters are predictive of postoperative major adverse cardiac events and unfavorable transplant outcomes.[2,3](#ref-0002) Lastly, an association does not imply causation,(#ref-0004) and both DD and early graft dysfunction may have an independent, common origin like cirrhotic cardiomyopathy.(#ref-0005) An adjustment for cofounders is, therefore, mandatory; regrettably, the omission of a multivariable analysis from the study obfuscates the interpretation of the observed association. Presumably, DD results in early allograft rejection and dysfunction via the attendant elevated pro-inflammatory cytokines, or increased venous pressure and hepatic allograft congestion.(#ref-0006) Postoperative cardiac variables (e.g., troponins, sono- and electrocardiography, venous and pulmonary pressures) and allograft biopsies were not reported in the study, but may direct clinicians to mitigating interventions to improve outcomes in liver allograft recipients with DD.
Background: Tako-tsubo syndrome (TTS) in its most typical form shares common features with anterior ST segment elevation myocardial infarction (AMI) during acute presentation. Differential diagnosis between the two conditions is often challenging especially if ST segment elevation is associated with extensive apical akinesis. Methods: we sought to systematically analyze ECG and echocardiographic parameters including LV longitudinal strain and two new indexes: the inferior-apex ratio (IAR) and the inferior-lateral-apex ratio (ILAR), to assess if ventricular involvement may be different in TTS and AMI. Results: A retrospective cohort study was conducted with 2 groups: patients with TTS (n=22) and patients with extensive anterior STEMI (n=22). Lack of ST elevation in V1 was associated with TTS with sensitivity and specificity of 86%, positive and negative predictive value of 86%. Longitudinal strain in mid inferior and mid inferior-lateral segments were more compromised in TTS: - 4.3±6.4% and -5.4± 5.4% in TTS vs -10.2±5.5% and -9.9 ±4.9% in AMI, respectively (P<0.01 for all). By multivariate analysis, both longitudinal strain values, inferior-apical ratio (IAR) <1 and inferior-lateral-apical ratio (ILAR) <1 were independently associated with diagnosis of TTS during acute phase. Conclusions: our results suggest that impaired contractility extending beyond apex to mid inferior and inferior-lateral walls can be easily assessed by IAR and ILAR, and these indexes facilitate non-invasive differentiation of TTS from extensive anterior STEMI.
Objective: To study the value of fetal epicardial fat thickness (EFT) in gestational diabetes mellitus in the third trimester of pregnancy and its relationship with clinical parameters and perinatal outcomes. Methods: A total of 80 participants, including 40 with diagnosed GDM and 40 healthy pregnant women, were included in the study. Demographic data were obtained from medical records. Sonographic examinations were performed, such as amniotic fluid value, fetal biometric measurements, and Doppler parameters of the umbilical artery. Fetal EFT values were measured at the free wall of the right ventricle using a reference line with echocardiographic methods. Correlation tests were performed to evaluate the relationship between fetal EFT and clinical and perinatal parameters. P < 0.05 were interpreted as statistically significant. Results: The fetal EFT value was statistically higher in the GDM group than in the control group (p:0.000). Spearman correlation tests revealed statistically significant but weak positive correlations between fetal EFT value, 1-hour 100-gr OGTT, birth weight, and BMI (r: 0.198, p:0.047; r:0.395, p:0.012; r:0.360, p:0.042, respectively). The optimal fetal EFT threshold for predicting GDM disease was found as 1.55 mm, with a specificity of 74.4% and sensitivity of 75.0%. Statistically significant differences between the two groups in umbilical artery Doppler resistance index (RI), pulsatility index (PI), and systolic/diastolic ratio (S/D) were not found (p:0.337; p:0.503; p:0.155;). BMI and amniotic fluid volume were higher in the GDM group compared to the control group (p:0.009; p:0.000). Conclusion: This study demonstrated that increased fetal EFT may occur as a reflection of changes in glucose metabolism in intrauterine life. Future studies with larger series, including the study of neonatal metabolic parameters, will contribute to the understanding of the importance of fetal EFT in determining the metabolic status of the fetus.
Background: Three-dimensional echocardiography (3DE) is an emerging method for volumetric cardiac measurements; however, few vendor-neutral analysis packages exist. Ventripoint Medical System Plus (VMS3.0+) proprietary software utilizes a validated MRI database of normal ventricular and atrial morphologies to calculate chamber volumes. This study aimed to compare left ventricular (LV) and atrial (LA) volumes obtained using VMS3.0+ to Tomtec echocardiography analysis software. Methods: Healthy controls (n=98) aged 0 to 18 years were prospectively recruited and 3D DICOM datasets focused on the LV and LA acquired. LV and LA volumes and ejection fractions were measured using TomTec Image Arena 3D LV analysis package and using VMS3.0+. Pearson correlation coefficients, Bland-Altman’s plots and intraclass coefficients (ICC) were calculated, along with analysis time. Results: There was a very good correlation between VMS and Tomtec LV systolic (r 2 = 0.88, ICC 0.89 [95% CI 0.81,0.94]), and diastolic (r 2 = 0.88, ICC 0.90 [95% CI 0.77,0.95]) volumes, and between VMS and Tomtec LA diastolic (r 2 =0.75, ICC 0.89 [95% CI 0.81,0.93]) and systolic (r 2 =0.88, ICC 0.91 [95% CI 0.78,0.96]) volumes on linear regression models. Natural log transformations eliminated heteroscedasticity, and power transformations provided best fit. The time (mins) to analyze volumes using VMS were less than using Tomtec (LV VMS 2.3±0.5, Tomtec 3.3±0.8, p<0.001; LA: VMS 1.9±0.4, Tomtec 3.4±1.0, p<0.001). Conclusions: There was very good correlation between knowledge-based (VMS3.0+) and 3D (Tomtec) algorithms when measuring 3D echocardiography derived LA and LV volumes in pediatric patients. VMS was slightly faster than Tomtec in analyzing volumetric measurements.
Herein we present a case of concomitant congenital anomalies with an iatrogenic defect. The female patient underwent a percutaneous mitral balloon valvuloplasty due to rheumatic mitral stenosis. Unfortunately, an iatrogenic atrial septal defect (ASD) occurred and also, partial anomalous pulmonary venous return was observed at post-procedure evaluation. The patient had severe symptoms and the right heart chambers were dilated on imaging. But perhaps, the most crucial point was that the patient was planning a pregnancy. After a difficult and patient-involved decision process, the patient underwent to successful robotic surgery for iatrogenic ASD and partial anomalous pulmonary venous return. After operation, the patient was asymptomatic and right heart chambers normalized.
COVID-19 related MIS-C (Multisystem inflammatory syndrome in children) can present with cardiovascular complications like shock, arrhythmias, pericardial effusion, and coronary artery dilatation. The majority of MIS-C associated coronary artery abnormalities are dilation or small aneurysms which are transient and resolve in a few weeks[[1, 2]](#ref-0001). We present here a case of a 3-month-old child who was noted to have giant aneurysms of her coronary arteries (LAD and RCA) twenty-six days after testing positive for COVID-19. She was treated with IVIG, infliximab, and glucocorticoids along with aspirin, clopidogrel and enoxaparin. She did not show any signs of coronary ischemia or cardiac dysfunction but continued to have persistent giant coronary artery aneurysms involving the LAD (z-score ~35) and RCA (z-score ~30) [Fig. 1]. This study emphasizes the importance of early detection and aggressive management of MIS-C to prevent potentially life-threatening consequences.
Objectives In stress echocardiography (SE), dipyridamole (DIP) and dynamic stress (ExSE) are reported as safer than dobutamine stress (DSE). We investigated whether commonly used stressors cause myocardial injury, measured by high sensitivity troponin T (hsTnT). Methods 135 patients (DSE n=46, ExsE n=46, DIP n=43) with negative SE were studied. Exclusion criteria were known ischemic heart disease (IHD), baseline wall motion abnormalities, left ventricle systolic dysfunction/regional wall motion abnormalities, septum/posterior wall ≥13 mm, diabetes, baseline hsTnT level ≥14 ng/L, baseline blood pressure ≥160/100 mmHg, peak pulmonary pressure ≥45mmHg, eGFR <1mL/s/1.73m2, more than mild to moderate valvular disease and dobutamine side effects. HsTnT was measured before and 180 minutes after the test. Results All patients had low pre-test probability of IHD. HsTnT increased in DSE, less so in ExSE, and unchanged in DIP group [9.4 (1.5–58.6), 1.1 (-0.9–15.7), -0.1 (-1.4–2.1) ng/L, p<0.001]. In DSE, hsTnT change was associated with peak dobutamine dose (r=0.30, p= 0.045), test length (r=0.43, p=0.003) and atropine use (p<0001). In ExSE, hsTnT rise was more likely in females (p=0.012) and elderly (>65 years) (r=0.32, p=0.03), no association was found between atropine use (p=0.786) or test length and hsTnT rise (r=0.10, p=0.530). Conclusions DSE is associated with myocardial injury in patients with negative SE, no injury was observed in DIP and only mild one in ExSE. Whether myocardial injury is causative of the higher reported adverse event rates in DSE remains to be determined.
Aim: We aimed to examine fetal cardiac output (CO) in patients who recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Materials: This prospective study included 48 pregnant women recovered from SARS-CoV-2 infection and 50 control cases. SARS-CoV-2 infection was diagnosed by polymerase chain reaction (PCR) test in patients. Fetal echocardiographic evaluations were performed at 24-37 weeks of gestation in pregnant women who recovered from the infection and control group. Results: The median value of ultrasound evaluation was 34 (2.6) weeks of gestation in the recovery from the SARS-CoV-2 infection (RSI) group, and 32 (7.6) weeks in the control group (p=0.565). Left cardiac output (LCO) z score was significantly lower in the RSI group than the control group (p=0,041). LCO and combine cardiac output (CCO) z score were significantly lower in the severe disease group than mild, moderate disease groups, and controls (p=0,019 and p=0,013). CCO (mL/min/kg) was decreased in the severe disease group when compared with control and mild disease groups (p=0,044). Fetal distress, preterm delivery rate, and neonatal intensive care unit (NICU) admission were found to be higher in the severe disease group compared to the control group (p=0,010, p=0,009, and p<0,001 respectively). Conclusion: In the present study, fetal cardiac output in pregnant women with recovery from SARS-CoV-2 infection was found significantly decreased, especially in whom had severe diseases. Placental dysfunction and inflammatory cytokines might cause fetal cardiac changes. Further studies could be clarified on the impact of SARS-CoV-2 infection on fetal cardiac function.
We report a rare case of multiple giant coronary artery aneurysms combined with anomalous aortic origin of left coronary artery in a 30-years old man precisely diagnosed by multimodality imaging, including echocardiography, coronary computed tomographic angiography (CCTA), cardiac magnetic resonance imaging (CMR) and selective coronary angiography. The imaging results were finally confirmed by surgery. We present the clinical value of multimodality imaging in diagnosing coronary artery aneurysm and anomalous origin.
Background: Accessory mitral valve tissue (AMVT) is an extremely rare causes left ventricular outflow tract (LVOT) obstruction and is usually incidentally detected in childhood. It is often associated with other cardiac and vascular congenital malformations. Case Presentation: In this case, we present a 15-year-old girl was diagnosed with AMVT by transesophageal echocardiography, resulting in LVOT obstruction during systole. Interestingly enough, the patient’s accessory mitral valve remained undetected for years until he became symptomatic for wide ASD. Successful closure of the ASD with resection of the AMVT was performed with a transaortic approach. The patient was hemodynamically stable postoperatively. There were no abnormalities in the mitral valves and LVOT. Conclusion: It was also unusual to see AMVT with ASD instead of other frequently associated other congenital anomalies. Accessory mitral valve should be considered a rare but important cause of left ventricular outflow tract obstruction in childhood.
[Abstract] Objective To review the imaging characteristics and evaluate the diagnostic value of echocardiography for fetal congenitally unguarded tricuspid valve orifice (CUTVO). Methods Doppler echocardiography was performed and the images were compared with operative and necropsy findings in ten fetuses with CUTVO. The aim of the study was to summarize the characteristics of fetal echocardiography and analyze the causes of missed diagnoses and misdiagnoses. Results There were six cases with complete absence and four cases with partial absence of the tricuspid leaflet. In seven of ten cases the pregnancy was terminated. In six cases CUTVO was confirmed by autopsy after induced labor, while one case had no autopsy. After birth, one case died due to severe illness. The two remaining cases survived with an atrial septal defect and patent ductus arteriosus on postpartum ultrasonic scans. These cases underwent surgical treatment resulting in less moderate tricuspid regurgitation. Among all cases, four were misdiagnosed and diagnosis for CUVTO missed, but CUVTO was demonstrated after induced labor. CUTVO ultrasonographic characteristics consist of the atrioventricular connection with normal arteries and the tricuspid valve device partially or completely absent. The annulus of the tricuspid valve can be describe as “empty” in the apical 4-chamber view, Doppler evaluation shows to-and-fro flow across the tricuspid orifice with low velocity and two-way spectrum. Conclusion diagnosis and differential diagnosis of CUTVO by fetal echocardiography has important clinical value.
A 22-year male presented with complaints of dyspnea. Multimodality imaging revealed a polypoidal right atrial mass with sub-massive pulmonary embolism. The patient underwent urgent surgery. The pathological examination confirmed it as cardiac myxoma. Cardiac myxoma, a most common primary cardiac tumor, is commonly found in the left atrium. The right atrium is an uncommon site and the usual mode of presentation is the tumor or thrombus embolisation to the pulmonary circulation.
Right atrial appendage aneurysms (RAAAs) are extremely rare in cardiac anomaly. According to the literature, no more than 25 cases have been reported so far, among which only 3 cases were children. Here, we reported an infant with a giant RAAA and severe symptoms. The RAAA was diagnosed by echocardiography and surgically resected under cardiopulmonary bypass. The role of transesophageal echocardiography was very important during the aneurysm resection surgery, which helped surgeons to plan surgical procedures during the surgery and evaluate the surgical effect postoperatively.
Bioprosthetic valve thrombosis is a growing recognized entity, especially with the increasing use of the valve in vale procedures and the advent of new detection technologies (e.g., 4D CT and 4D echocardiography). However, the optimal management strategy in the acute context is not established. This paper presents a case of early thrombosis following the percutaneous tricuspid valve in vale procedure that was successfully managed with thrombolysis.
Ruptured abdominal aortic aneurysms are associated with high mortality rates and require prompt diagnosis with subsequent intervention. CT scan is considered the gold-standard for diagnosis, however, in the acute setting ultrasound may be a reasonable diagnostic test for certain patients. We report a case that demonstrates the utility of bedside ultrasound of rAAA for a patient in extremis. Also, we provide a brief review of literature for the diagnosis of rAAA with ultrasound.
Massive myocardial calcification is a very rare finding. Accurate identification and characterization may help the clinicians to determine the etiology and clinical significance. In this case, the diagnostic pathway excluded previous myocardial infarction, myocarditis and calcium-phosphate disorders. A possible dystrophic etiology was considered. There are no standardized imaging features available to classify specific subtypes of intramyocardial calcifications. The relative merits of cardiac computed tomography and magnetic resonance in providing complimentary diagnostic information for calcific myocardial lesions is shown. Knowledge of the potential etiology and their imaging patterns are important to provide a concise and accurate differential diagnosis.