A document by Roman Komorovsky. Click on the document to view its contents.

Background: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a major cause of postoperative morbidity and mortality. Despite the availability of multiple imaging parameters, none of these parameters had adequate predictive accuracy for post-LVAD RVF. Aim: To study whether right ventricular pressure-dimension index (PDI), which is a novel echocardiographic index that combines both morphologic and functional aspects of the right ventricle, is predictive of post-LVAD RVF and survival. Methods: 49 cases that underwent elective LVAD implantation were retrospectively analyzed using data from an institutional registry. PDI was calculated by dividing systolic pulmonary artery pressure to the square of the right ventricular minor diameter. Cases were categorized according to tertiles. Results: Patients within the highest PDI tertile (PDI>3.62 mmHg/cm2) had significantly higher short-term mortality (42.8%) and combined short-term mortality and definitive RVF (50%) compared to other tertiles (p<0.05 for both, log-rank p for survival to 15th day 0.014), but mortality was similar across tertiles in the long-term follow up. PDI was an independent predictor of short-term mortality (HR:1.05–26.49, p=0.031) and short-term composite of mortality and definitive RVF (HR:1.37–38.87, p=0.027). Conclusions: Increased PDI is a marker of an overburdened right ventricle. Heart failure patients with a high PDI is at risk for short-term mortality following LVAD implantation.

Prosthetic valve endocarditis is a rare but serious complication of cardiac valve replacement, and echocardiography plays a fundamental role in its diagnosis and management. However, there is not much information about the use of the 3D transillumination rendering in this context. In this report we present an unusual case of prosthetic valve endocarditis that exemplifies the utility of this new tool.

Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Three-dimensional assessment of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onwards. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This semiautomatic technique reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of a semiautomatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.

Attempting a comprehensive examination of the fetal heart remains challenging for unexperienced operators as it emphasizes the acquisition and documentation of sequential cross-sectional and sagittal views and inevitably results in diminished detection rates of fetuses affected by congenital heart disease. The introduction of three-/four-dimensional spatial-temporal image correlation 3D/4D STIC technology facilitated a volumetric approach for thorough cardiac anatomic evaluation by the acquisition of cardiac 4D datasets by analyzing and correlating numerous images from different heart cycles obtained during an automated sweep and subsequently displaying them in an endless cine loop sequence. However, postanalysis with manipulation and repeated slicing of the volume usually requires experience and in-depth anatomic knowledge, which limits the widespread application of this advanced technique in clinical care and unfortunately leads to the underestimation of its diagnostic value to date. Fetal intelligent navigation echocardiography (FINE), a novel method that automatically generates and displays 9 standard fetal echocardiographic views in normal hearts, has shown to be able to overcome these limitations. Very recent data on the detection of congenital heart defects (CHDs) revealed a sensitivity and specificity of 98 % and 93 %, respectively. In this two-part manuscript, we focused on the performance of FINE in delineating abnormal anatomy of typical right and left heart lesions and thereby emphasized the educational potential of this technology for more than just teaching purposes. We further discussed recent findings regarding these morphological changes seen in a pathophysiological and/or functional context.

Congenital left atrial appendage aneurysm is an extremely rare anomaly. It is seen at any time ranging from fetal to ninth decade of life. Patients with left atrial appendage aneurysm may be asymptomatic, or present with dyspnea, arrhythmias, thromboembolic phenomenon. We report a case of prenatal diagnosis at 26 weeks of gestation , postnatal management and outcome of left atrial appendage aneurysm.

Aortic atresia is uncommonly associated with atrioventricular and ventriculoarterial discordance.(1) Presence of severe regurgitation of Ebsteinoid malformation of the tricuspid valve in this subset results in reduced aortic blood flow in-utero. The hemodynamic explanation of this anomaly was reported by Celermajer and colleagues.(2) We report here a term neonate with this anomaly detect antenatally.

Background: Ibrutinib is associated with atrial fibrillation (AF), though echocardiographic predictors of AF have not been studied in this population. We sought to determine whether left atrial (LA) strain on transthoracic echocardiography could identify patients at risk for developing ibrutinib-related atrial fibrillation (IRAF). Methods: We performed a retrospective review of 66 patients who had an echocardiogram prior to ibrutinib treatment. LA strain was measured with TOMTEC Imaging Systems, obtaining peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) on 4-chamber and 2-chamber views. Statistical analysis was performed with Chi-square analysis, T-test, or binomial regression analysis, with a p-value < 0.05 considered statistically significant. Results: Twenty-two patients developed IRAF (33%). Age at initiation of ibrutinib was significantly associated with IRAF (65.1 years vs. 74.1 years, p = 0.002). Mean ibrutinib dose was lower among patients who developed IRAF (388.2 ± 121.7 vs. 448.6 ± 88.4, p = 0.025). E/e’ was significantly higher among patients who developed IRAF (11.5 vs. 9.3, p = 0.04). PALS was significantly lower in patients who developed AF (30.3% vs. 36.3%, p = 0.01). On multivariate regression analysis, age, PALS and PACS were significantly associated with IRAF. On multivariate regression analysis, only PACS remained significantly associated with IRAF while accounting for age. Conclusions: Age, ibrutinib dose, E/e’, and PALS on pre-treatment echocardiogram were significantly associated with development of IRAF. On multivariate regression analyses, age, PALS and PACS remained significantly associated with IRAF. Impaired LA mechanics add to the assessment of patients at risk for IRAF

Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, whilst performing transthoracic echocardiography. Method and results: A referred 46-year-old male, with a history of exertional dyspnea for almost three months, was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site , so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV. Conclusion: Contrast-Enhanced Echocardiography by direct intracoronary injection of SonoVue contrast agent, is safe and can aid in the delineation of fistula drainage.

Cardiac imaging is the cornerstone of defining the etiology, quantification and management of mitral regurgitation (MR). This continues to be even more so the case with emerging trans-catheter techniques to manage MR. Transthoracic echocardiography remains the first line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative non-visual estimation, 3D volumetric data, late gadolinium, T1 and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.

Purpose: Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity. Methods: This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥ 4 mmHg. Mitral valve area by the continuity equation (MVACEQ) was used as an independent reference. The DMSI was calculated as follows: DMSI = VTILVOT / VTIMV. All-cause mortality data were collected retrospectively. Results: A total of 64 patients with DMS and 24 patients with RMS were identified. MVACEQ was larger in patients with DMS (1.43  0.4 cm2) than RMS (0.9  0.3 cm2) by ~0.5 cm2 (p = <0.001) and mean TMPG was lower in the DMS group (6.0 2 vs. 7.93 mmHg, p=0.003). A DMSI of  0.50 and ≤ 0.351 were associated with MVACEQ ≤ 1.5 and MVACEQ ≤ 1.0 cm2 (p<0.001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a non-significant trend towards worse survival in patients with MVACEQ ≤ 1.0 cm2 and DMSI ≤ 0.35, suggesting severe stenosis severity. Conclusion: Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.

Abstract Background: Transthoracic echocardiography (TTE) in prone position is challenging. Innovative use of transesophageal echocardiography (TEE) probe to perform TTE for such patients was described; but reproducibility and correlation of the TTE measurements by this technique with those obtained by the standard supine TTE study are still unknown. Methods: We enrolled 30 non-COVID-19 individuals, with a mean (SD) age 35 (10.9) years and 11 females, to study the agreement between the transthoracic measurements of the left ventricular (LV), left atrial (LA) and aortic dimensions obtained in prone position using an external TEE probe versus the standard supine position using the conventional TTE probe. Results: There were no significant differences between LV end-diastolic and end-systolic diameters, septal wall thickness, posterior wall thickness and aortic root dimensions in the prone versus the supine positions. While the mean ejection fraction (EF) (60.3% vs. 63.1%, P = 0.014) and mean LA dimensions (1.8 vs. 1.9 cm/m2, P < 0.001) were significantly lower in the prone position. The mean time of scans was significantly longer in the prone as compared to the supine (12.5 vs 4.5 minutes, P < 0.001). All supine studies had good quality while in the prone position 4 studies were of poor quality, and one was non-diagnostic. Conclusions: Assessment of cardiac dimensions and systolic function in the prone position using transthoracic TEE probe was feasible. LV and aortic dimensions agreed well with the standard TTE in supine position, however, LA dimensions and EF were lower in the prone position.

A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting) a single venous cannula was placed across the interatrial septum so the distal orifice and side ports were located within the left atrium and the proximal set of side ports at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.

Background This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-Fluorodeoxyglucose–Positron Emission Tomography (FDG-PET) are limited by cost and availability. Methods We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD) between the sarcoidosis group and controls. A random effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics. Results Nine studies with 967 patients were included in our analysis. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, p< 0.001, also was significantly lower in patients who suffered Major Cardiac Events(MCE), -3.89, 95% CI -6.14, -1.64, p< 0.001 . GCS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD: -3.33, 95% CI -4.71, -1.95, p< 0.001 Conclusion LVGLS and GCS were significantly lower in extra-cardiac sarcoidosis patients despite not exhibiting any cardiac symptoms. LVGLS correlates with MCEs in CS. Further studies are required to investigate the role of STE in the early screening of CS.

Cardiac injury presents a great challenge to the emergency doctors because these injuries require urgent intervention to prevent death. Sometimes serious cardiac injury may manifest only subtle or occult symptoms or signs. Cardiac foreign bodies induced cardiac penetrating injury infrequently and may lead to unpredictable complications, especially for those with sharp nature. However, we know little about the migrating paths or the foreign bodies location changes of such cases. As there is a rarely reported case of cardiac penetrating injury caused by a self-inflicted needle that migrated from the neck to the heart, we herein present a review of such injury on dynamic monitoring using perioperative echocardiography showed the needle shuttled through the ventricular wall along with increasing pericardial effusion.

Vascular rings(VRs) are defined as congenital abnormalities of the aortic arch and its branches. The most common vascular rings include right aortic arch (RAA) and double aortic arches(DAA). Vascular rings can form a ring that may compress the esophagus and trachea ,which likely result feeding difficulties and respiratory distress. We have reported three cases about diagnosis of vascular rings using High-definition flow(HD-flow) render mode and spatiotemporal image correlation(STIC). In addition ,we have evaluated the postnatal imaging features of vascular rings.

Background: The change of left ventricular function deteriorated with age because of gradual increases of blood pressure may result in increased energy loss (EL) in left ventricle (LV). The present study investigated EL in LV among hypertensive elderly patients and examined factors contributing to EL. Methods: A single-center retrospective study was performed on elderly hypertensive outpatients (65 years) who underwent echocardiography (N=105). EL in the LV was measured using an vector flow mapping system, and factors affecting peak EL during the early diastolic phase (ED-EL), late diastolic phase (LD-EL), and systolic phase (Sys-EL) were evaluated. Result: Mean age was 79.9±6.4 years (male 43%). Mean ED-EL, LD-EL, and Sys-EL were 42.1±46.7, 75.6±60.2, and 40.4±40.2 mJ/N/s. In a stepwise regression analysis, the E wave peak velocity of transmitral flow (unstandardized B=0.002, 95%CI 0.001 to 0.002, standardized β=0.547, p<0.001) and stroke volume in the LV outflow tract (LVOT) (B=0.001, 95%CI 0.000 to 0.001, β=0.190, p=0.034) were identified as factors affecting ED-EL. The factors affecting LD-EL were the E/A ratio (B=-0.122, 95%CI -0.180 to -0.064, β=-0.451, p<0.001) and peak velocity in LVOT (unstandardized B=0.001, 95%CI 0.0001 to 0.001, β=0.339, p=0.003). The factors influencing Sys-EL were peak velocity in LVOT (B=0.001, 95%CI 0.001 to 0.001, β=0.619, p<0.001) and the E/A ratio (B=-0.050, 95%CI -0.087 to -0.013, β=-0.241, p=0.008). Conclusion: Peak EL in the LV was higher during diastolic phase than systolic phase among elderly hypertensive patients. Peak EL during each phase was affected by systolic blood flow in LVOT and LV transmitral flow.

Bioprosthetic valve thrombosis (BPVT) is more common than previously thought and likely underreported. BPVT can be accurately diagnosed with cardiac imaging and treated successfully with anticoagulation, thus preventing re-operation. We hereby report a case of recurrent BPVT in the mitral position successfully treated with anticoagulation along with review of literature.