Epicardial Real-Time Three-Dimensional Echocardiography in Cardiac Surgery: A Preliminary Experience

How to manage an athlete with mitral valve prolapse

INTRODUCTION

Under the term degenerative mitral valve prolapse different pathophysiological and clinical entities coexist in a spectrum ranging from Barlow's disease to fibroelastic deficiency, and represent the most common cause of mitral regurgitation in the general population and in athletes. Carrying a mitral valve prolapse is usually considered a benign condition for athletes, but recently the scientific literature has focused on the malignant, thus rare, arrhythmic mitral valve prolapse and its dramatic association with sudden cardiac death, so that specific features should be considered a red flag and prompt additional exams before clear for competition.

DISCUSSION

As the athlete's heart is morphologically accompanied by remodelling and dilatation of the cardiac chambers induced by exercise, it may be challenging to differentiate the degree of left ventricular and atrial dilation induced by significant mitral regurgitation from physiological remodelling, especially in endurance athletes.

CONCLUSION

This how-to article provides clinical and useful data to manage athletes with mitral valve prolapse and to distinguish high-risk athletes carrying the features of arrhythmic mitral valve prolapse.

Epicardial Echocardiography in Pediatric and Congenital Heart Surgery

Epicardial echocardiography (e-echo) is a useful approach to intraoperative imaging for the smallest patients and in those with contraindications to transesophageal echocardiography (TEE). The e-echo has additional advantages that include improved visualization of anterior and vascular structures and three-dimensional capabilities. In this review, we describe the advantages and disadvantages of e-echo versus TEE for pediatric and congenital heart surgery with the goal of enhancing the utility and feasibility of the former among congenital heart surgeons. We also review the technique for performance of an e-echo and provide demonstrations of the images obtained for select lesions.

Biological Niches within Human Calcified Aortic Valves: Towards Understanding of the Pathological Biomineralization Process

Despite recent advances, mineralization site, its microarchitecture, and composition in calcific heart valve remain poorly understood. A multiscale investigation, using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and energy dispersive X-ray spectrometry (EDS), from micrometre up to nanometre, was conducted on human severely calcified aortic and mitral valves, to provide new insights into calcification process. Our aim was to evaluate the spatial relationship existing between bioapatite crystals, their local growing microenvironment, and the presence of a hierarchical architecture. Here we detected the presence of bioapatite crystals in two different mineralization sites that suggest the action of two different growth processes: a pathological crystallization process that occurs in biological niches and is ascribed to a purely physicochemical process and a matrix-mediated mineralized process in which the extracellular matrix acts as the template for a site-directed nanocrystals nucleation. Different shapes of bioapatite crystallization were observed at micrometer scale in each microenvironment but at the nanoscale level crystals appear to be made up by the same subunits.

Value of transesophageal 3D echocardiography as an adjunct to conventional 2D imaging in preoperative evaluation of cardiac masses

BACKGROUND

This study sought to compare three-dimensional (3D) and two-dimensional (2D) transesophageal echocardiography (TEE) to assess intracardiac masses. It was hypothesized that 3D TEE would reveal incremental information for surgical and nonsurgical management.

METHODS

In 41 patients presenting with intracardiac masses (17 thrombi, 15 myxomas, 2 lymphomas, 2 caseous calcifications of the mitral valve and one each of hypernephroma, hepatocellular carcinoma, rhabdomyosarcoma, lipoma, and fibroelastoma), 2D and 3D TEE were performed, aiming to assess the surface characteristics of the lesions, their relationship to surrounding structures, and attachments. Diagnoses were made by histopathology (n = 28), by computed tomography (n = 8), or by magnetic resonance imaging (n = 5). Benefit was categorized as follows: (A) New information obtained through 3D TEE; (B) helpful unique views but no additional findings compared to 2D TEE; (C) results equivalent to 2D TEE; (D) 3D TEE missed 2D findings.

RESULTS

In 15 subjects (37%), 3D TEE revealed one or more items of additional information (category A) regarding type and site of attachment (n = 9, 22%), surface features (n = 6, 15%), and spatial relationship to surrounding structures (n = 8, 20%). In at least 18% of all intracardiac masses, 3D TEE can be expected to deliver supplementary information. In six patients, additional findings led to decisions deviating from those made on the basis of 2D TEE. In 11 subjects (27%), 3D echocardiographic findings were categorized as "B."

CONCLUSIONS

Information revealed by 3D imaging facilitates therapeutic decision making and especially the choice of an optimal surgical access prior to removal of intracardiac masses.