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. 7.93 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.
Introduction In the current literature, several studies show that pulmonary artery stiffness (PAS) is associated with right ventricular (RV) dysfunction, pulmonary arterial hypertension (PAH), and disease severity in patients with structural heart disease, human immunodeficiency virus (HIV), and chronic lung disease. Hence, in this study, we aimed to use PAS to show the early changes in the pulmonary vascular bed in patients with cirrhosis. Material and Methods In this prospective, cross-sectional study, 39 subjects who were being followed up with cirrhosis and 41 age- and sex-matched healthy participants were enrolled. For each case, the PAS value was calculated by dividing mean peak velocity of the pulmonary flow by the pulmonary flow acceleration time (PfAT). Results The measured PAS was 23.62 ± 5.87 (Hz/msn) in cirrhotic patients and 19.09 ± 4.16 (Hz/msn) in healthy subjects (p < 0.001). We found a positive statistical significance between PAS and systolic pulmonary arterial pressure (sPAP) (r = 0.378; p = 0.001). PAS was an independent predictor that was associated with cirrhosis disease according to multivariate logistic regression analysis (OR: 1.209; 95% CI: 1.059–1.381; p = 0.005). Conclusion Based on the study results, we consider that PAS may help in the early detection of changes in the pulmonary vascular bed, even if the RV function parameters or sPAP are within the normal range.
Pulmonary artery sling (PAS) and tracheal agenesis (TA) are both very rare diseases. Most of PAS are associated with tracheal bronchial malformations. However, PAS associated with TA have not yet been reported so far. Here, we report one case of PSA associated with TA diagnosed prenatally in our hospital. Due to the extremely low incidence of two diseases, physicians do not have sufficient understanding of these disease, prenatal ultrasound examination found that these kinds of diseases are very challenging and confusable. Prenatal ultrasound and MRI examination of pulmonary artery branches, trachea and esophagus will provide useful information. Improving the accuracy of prenatal fetal diagnosis is helpful for perinatal management and counseling.
In the current literature, we observed a tendency to describe normal values of echocardiographic measurements by means of the Z-score. In fetal cardiology, these Z-score equations are still being established. Measurement of myocardial thickness is an important assessment especially in fetuses of diabetic pregnant women because of the risk of developing myocardial hypertrophy secondary to elevated maternal blood glucose levels. To determine the percentiles and to develop the Z-score equations of right and left ventricular lateral wall and interventricular septum measurements using two-dimensional echocardiography in normal fetuses between 24 and 34 weeks of gestation. This is a prospective cross-sectional study that was performed in single fetuses with normal heart and in non-diabetic pregnant women. Measurements of the lateral wall of the right and left ventricles and the interventricular septum were made. 873 pregnant women were included. We determined the percentiles of the measurements for each gestational age. The Z-score equation was developed for each of the measurements: right ventricular lateral wall measurement [RVLW = x - (- 1 + 0.109 * GI) / 0.4], left ventricle lateral wall measurement [LVLW = x - (- 1.366 + 0.12 * GI) / 0.43] and the interventricular septum in the four-chamber plane [IVS4ch = (x - (- 1,113+ 0.107 * IG) / 0.4] and the interventricular septum in the left ventricular outflow tract plane [IVSLVOT = (x - (-0.581 + 0.084 * GI) / 0.35]. The present study allowed to demonstrate the percentiles and the Z-score equations for each of the measures studied.
Background: Stress echocardiography (SE) is an established technique for assessment of coronary artery disease (CAD) which is difficult to perform and interpret. Left ventricular stroke volume (SV) is readily estimated with Doppler echocardiography. It can be affected by myocardial ischemia, with possible adjunctive value during SE. Methods: Patients underwent Bruce protocol SE with SV estimated before and after maximal treadmill exertion post routine regional wall analysis. Incremental change in SV (ΔSV) with exercise was measured. Results: A derivation cohort (n=273) was established to test the hypothesis. An optimal cut-off for detection on inducible ischemia was ΔSV ≤ +10ml. The validation cohort of consecutive patients (n = 1093, 376 [34%] female; age 59±12 years) were followed clinically after SE for 20,460 patient-months. There were 1000 patients with non-ischemic SE, and 93 patients with studies suggestive of myocardial ischemia. Secondary analysis yielded 831 patients with a normal exercise response (ΔSV > +10ml) and 192 with an abnormal ΔSV ≤ +10ml. Time to first combined adverse cardiac event (composite of angina, acute coronary syndrome, cardiac revascularization, worsening New York Heart Association (NYHA) class, a reduction in EF, and cardiovascular death) was analysed and adjusted using Cox proportional hazards regression. The hazard ratio for an adverse event with an abnormal ΔSV response (≤10ml) was 10.3 (95% confidence intervals 5.6-19.1, p<0.0001). Conclusions: SV assessment during SE is feasible and readily performed. It is simple, practical and has incremental diagnostic and prognostic value when added to exercise regional wall motion analysis.
Hypertrophic cardiomyopathy is a common heritable cardiomyopathy with various clinical phenotypes. A rare spiral variant has been recently reported that has been associated with adverse outcomes and has traditionally been diagnosed using cardiac magnetic resonance. We report a case of the rare variant spiral hypertrophic cardiomyopathy where we used transthoracic echocardiography with an ultrasound enhancing agent to demonstrate the geometry of spiral hypertrophic cardiomyopathy and compared to simultaneous cardiac MRI images. The use of echocardiography with ultrasound enhancing agents may prove to be a valuable tool in identifying the geometry of hypertrophic cardiomyopathy variants in selected patients.
Classical absent pulmonary valve syndrome (APVS) with tetralogy of Fallot (TOF) is a rare congenital cardiac anomaly commonly associated with absent of patent ductus arteriosus (PDA), which is mostly diagnosed after 20 weeks of gestation by fetal echocardiography. This case of APVS with TOF was suspected at 13 weeks of gestation and diagnosed at 14 weeks of gestation with an obvious PDA. The pulmonary arterial trunk and the branches did not dilated obviously. 15 days later, the PDA narrowed down with the discovery of pulmonary artery ectasia at the same time. This progress indicated that the absent of PDA is not necessary for the survival of APVS with TOF in utero, in contrast, the absent or restriction of PDA may be nothing less than adaptation to the disease. Fetal autopsy confirmed the accuracy of fetal echocardiography. Chromosome microarray analysis (CMA) showed 20p12 deletion in this fetus, which is rare among TOF cases.