[The EDEC curriculum-the path to advanced echocardiography in the intensive care unit]

Good knowledge of echocardiography is essential for modern intensive care medicine. A standardized curriculum for acquiring the expertise to perform TTE and TEE is a good way to strengthen one's own diagnostic skills.The EDEC curriculum from ESICM, which has been established for years, offers a good opportunity for structural further training at the advanced level in combination with gaining a high level of professional competence.

Fleshing Out the Invisible: A Pericardial Paraganglioma

•Pericardial paragangliomas can present with angina and dyspnea. •TTE is often the first-line test for assessing pericardial tumors. •Long sweeps and contrast enhancement may enhance visualization of pericardial masses. •Multimodality imaging may help differentiate malignant from benign tumors.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

Using WeChat to guide preparation before transthoracic echocardiography reduces anxiety and improves satisfaction of parents of infants with congenital heart disease

OBJECTIVE

To explore the effect of using WeChat to guide preparation before transthoracic echocardiography (TTE) on reducing anxiety and improving the satisfaction of parents of infants with congenital heart disease (CHD).

METHODS

This study was a retrospective study conducted in a children's hospital. The clinical data of 44 patients and the anxiety and satisfaction data of their parents who received WeChat guidance were collected between December 2021 and January 2022 (the WeChat group). The corresponding data of 47 patients and their parents who received educational brochure guidance were collected between September 2021 and November 2021 (the routine group). Guidance was used to help the parents prepare for TTE performed by medical professionals. The State-Trait Anxiety Inventory scale and the Patient Satisfaction Questionnaire-18 (PSQ-18) were used. The data of the two groups were compared and analyzed.

RESULTS

The comparison of parental anxiety between the two groups showed that the scores of state anxiety and trait anxiety in the WeChat group were significantly lower than those in the routine group (p < 0.05). The comparison of the results of the PSQ-18 showed that the scores for general satisfaction, interpersonal manner, communication, time spent with the physician, and accessibility and convenience in the WeChat group were significantly higher than those in the routine group (p < 0.05).

CONCLUSION

Using WeChat to guide preparation before TTE for infants with CHD can effectively reduce the anxiety of their parents and improve their parents' satisfaction with medical treatment.

Advantages of Multiposition Scanning in Echocardiographic Assessment of the Severity of Discordant Aortic Stenosis

AIM OF THE STUDY

The aim of this study was to perform a comparative analysis of severity of discordant aortic stenosis (AS) assessment using multiposition scanning and the standard apical window.

MATERIALS AND METHODS

All patients (n = 104) underwent preoperative transthoracic echocardiography (TTE) and were ranked according to the degree of AS severity. The reproducibility feasibility of the right parasternal window (RPW) was 75.0% (n = 78). The mean age of the patients was 64 years, and 40 (51.3%) were female. In 25 cases, low gradients were identified from the apical window not corresponding to the visual structural changes in the aortic valve, or disagreement between the velocity and calculated parameters was detected. Patients were divided into two groups: concordant AS (n = 56; 71.8%) and discordant AS (n = 22; 28.2%). Three individuals were excluded from the discordant AS group due to the presence of moderate stenosis.

RESULTS

Based on the comparative analysis of transvalvular flow velocities obtained from multiposition scanning, the concordance group showed agreement between the velocity and calculated parameters. We observed an increase in the mean transvalvular pressure gradient (ΔP_mean) and peak aortic jet velocity (V_max), ΔP_mean in 95.5% of patients, velocity time integral of transvalvular flow (VTI AV) in 90.9% of patients, and a decrease in aortic valve area (AVA) and indexed AVA in 90.9% of patients after applying RPW in all patients with discordant AS. The use of RPW allowed the reclassification of AS severity from discordant to concordant high-gradient AS in 88% of low-gradient AS cases.

CONCLUSION

Underestimation of flow velocity and overestimation of AVA using the apical window may lead to misclassification of AS. The use of RPW helps to match the degree of AS severity with the velocity characteristics and reduce the number of low-gradient AS cases.

Persistent left superior vena cava: Case report

Persistent left superior vena cava (PLSVC) is a rare anomaly of the systemic venous circulation. We report the case of a 22-year-old female that had history of multiple repair surgeries for her esophageal atresia, as well as a right lobectomy for bronchiectasis 15 years prior. She was admitted to the surgical ward for complete resection of the right lung. A trans-thoracic echocardiography was performed as part of the pre-surgical work-up and it revealed a dilated coronary sinus which led us to suspect the presence of a PLSVC. The latter was confirmed by a simple “Bubble study” and confirmed by CT angiogram. We will discuss throughout this paper, the clinical and radiological features, as well as the embryology of this anomaly, so that the knowledge of the existence of this anatomical variant, especially if surgery or catheterization is at reach of the medical team, may lead to avoid serious complications.

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes.

OBJECTIVE

We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes.

METHODS

We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS.

RESULTS

Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications.

CONCLUSIONS

We identified four pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 7

This month we focus on papers that provide insights into the potential for target trial emulation to be used in health technology assessment, the role of real-world evidence (RWE) in informing additional elements of value and the importance of RWE to European joint clinical assessments.

Transthoracic Echocardiography-Based Prediction Model of Adverse Event Risk in Patients with COVID-19

Cardiopulmonary disorders cause a significant increase in the risk of adverse events in patients with COVID-19. Therefore, the development of new diagnostic and treatment methods for comorbid disorders in COVID-19 patients is one of the main public health challenges. The aim of the study was to analyze patient survival and to develop a predictive model of survival in adults with COVID-19 infection based on transthoracic echocardiography (TTE) parameters. We conducted a prospective, single-center, temporary hospital-based study of 110 patients with moderate to severe COVID-19. All patients underwent TTE evaluation. The predictors of mortality we identified in univariate and multivariable models and the predictive performance of the model were assessed using receiver operating characteristic (ROC) analysis and area under the curve (AUC). The predictive model included three factors: right ventricle (RV)/left ventricle (LV) area (odds ratio (OR) = 1.048 per 1/100 increase, p = 0.03), systolic pulmonary artery pressure (sPAP) (OR = 1.209 per 1 mm Hg increase, p < 0.001), and right ventricle free wall longitudinal strain (RV FW LS) (OR = 0.873 per 1% increase, p = 0.036). The AUC-ROC of the obtained model was 0.925 ± 0.031 (95% confidence interval (95% CI): 0.863−0.986). The sensitivity (Se) and specificity (Sp) measures of the models at the cut-off point of 0.129 were 93.8% and 81.9%, respectively. A binary logistic regression method resulted in the development of a prognostic model of mortality in patients with moderate and severe COVID-19 based on TTE data. It may also have additional implications for early risk stratification and clinical decision making in patients with COVID-19.

Aortic Root Anatomy Is Related to the Bicuspid Aortic Valve Phenotype

BACKGROUND

Bicuspid aortic valve (BAV) is associated with an asymmetric (not circular) aortic root, resulting in variability in the aortic root diameter measurements obtained using different techniques. The objective of this study was to describe aortic root asymmetry, including its orientation in the thorax, in relation to the various phenotypes of BAV and its impact on aortic root diameter measurements obtained using transthoracic echocardiography.

METHODS

Aortic root asymmetry, orientation of the largest root diameter, and orientation of the valve opening were studied using computed tomographic scans of patients with BAV without significant aortic valve dysfunction referred for evaluation of a thoracic aortic aneurysm. Eighty-five patients with BAV were evaluated; BAV with fusion of the left and the right coronary cusps (L-R BAV), with or without raphe (n = 63), was compared with BAV with fusion of the right coronary and noncoronary cusps (N-R BAV), with or without raphe (n = 22).

RESULTS

Asymmetry of the aortic root and its orientation in the thorax can be predicted from BAV phenotype: orientation of the valve opening differed from orientation of the largest root diameter by nearly 75° in both groups. The angle of the largest root diameter with the reference sagittal plane was 64.3° in the L-R BAV group versus 143.1° in the N-R BAV group (P < .0001). Therefore, using the parasternal long-axis view on transthoracic echocardiography, in N-R BAV, the ultrasound beam is roughly parallel to the valve opening orientation and almost orthogonal to the maximum diameter of the root. On the contrary, in L-R BAV, the ultrasound beam is roughly perpendicular to the valve opening orientation and almost parallel to the maximum diameter of the root. Consequently, the parasternal long-axis view on transthoracic echocardiography significantly underestimates maximal aortic root diameter in N-R BAV and modestly underestimates root diameter in L-R BAV (-6.1 ± 0.96 vs -2.3 ± 0.47 mm, P = .0008).

CONCLUSIONS

Aortic root morphology in patients with BAV can be predicted by BAV phenotype: the largest root diameter is roughly perpendicular to the orientation of the valve opening. Therefore, echocardiographic measurements according to present recommendations (parasternal long-axis view) underestimate maximal diameter in patients with N-R BAV.

Multivalvular destruction as the primary presentation of aggressive infective endocarditis with subaortic valve membrane

Multivalvular destruction may be a clinical manifestation of infective endocarditis (IE), which is a devastating infection of the heart either alone or superimposed with congenital subaortic membrane as in this case report. Here, we report a case of multivavular destruction with severe vegetation presented as a manifestation of infective endocarditis (IE) in a neglected case of 18-year-old male with previous rheumatic heart disease. Transesophageal echocardiography is an important imaging modality for diagnosis of superimposed aortic and heart lesions. Early necessary investigation and correct diagnosis is mandatory to prevent bad complications.

A Rare Cause of Pulmonary Hypertension and Right Ventricular Failure: Left Atrial Myxoma

•

Left atrial myxomas can cause pulmonary hypertension and right-sided heart failure.

•

TTE can be used to identify an atrial mass and quantify its hemodynamic effects.

•

Excision of atrial myxoma is indicated to prevent obstructive physiology.

Cardiac hemangioma in a difficult anatomical location presented with ventricular tachycardia. A rare case report

Cardiac hemangioma is a benign and rare primary tumor of the heart. Though it has benign histopathological features, its complications can be life-threatening. We report a young adult male without any prior structural heart disease or medical history who presented with ventricular tachyarrhythmia. Echocardiography revealed an echogenic mass located intramurally in the left lateral ventricle and its distinctive characteristics were revealed with further imaging modalities. Though simple complete removal of the mass is the preferred treatment, its firm texture and thinned encircling myocardium prevented the total excision. In this case report, we discussed cardiac hemangioma, its potential complications and treatment options.

Utility of tissue Doppler imaging of systolic function to diagnose diastolic dysfunction in critically ill patients

BACKGROUND

Diastolic dysfunction might be associated with increased mortality in severe sepsis and septic shock. In 2016 new American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines were published. They simplify our approach to diastolic dysfunction recognition, but they were not validated in critical care settings. The aim of the study was to assess the applicability of systolic tissue Doppler imaging of left ventricle in patients with and without diastolic dysfunction classified on the basis of the new guidelines.

METHODS

Two echocardiographers analyzed transthoracic echocardiography (TTE) exa-minations and assigned patients according to ASE/EASCVI guidelines to three groups: patients with systolic dysfunction and diastolic dysfunction, patients with normal systolic function and diastolic dysfunction, and patients with normal systolic and diastolic function.

RESULTS

We performed 593 examinations in 320 patients and 390 examinations in 200 patients were included in the study. In 264 examinations with ejection fraction (EF) < 55% systolic and diastolic dysfunction was diagnosed (group 1). In 114 examinations with EF ≥ 55% normal systolic and diastolic function was diagnosed (group 2). In 12 examinations with EF ≥ 55% normal systolic and abnormal diastolic dysfunction was diagnosed (group 3). After analyzing mean systolic tissue Doppler of the mitral annulus we found a statistically significant difference between group 1 and 2 (P < 0.0001) and between group 2 and 3 (P < 0.0001). The difference in values of means in group 1 vs. 3 was not statistically significant (P = 0.853).

CONCLUSION

Systolic tissue Doppler analysis of mitral annulus might help to diagnose diastolic dysfunction especially in patients with preserved ejection fraction.

Risk for infective endocarditis in bacteremia with Gram positive cocci

PURPOSE

Infective endocarditis (IE) is a serious complication of bacteremia and is most often caused by Gram positive cocci. We investigated the prevalence of IE in patients where echocardiography was encouraged when bacteremia with Gram positive cocci was present.

METHODS

The study included patients with Gram positive cocci bacteremia hospitalized at two Danish hospitals between March and December 2016. Information concerning echocardiography, demographics and bacterial species was collected from the patients' medical files. Patients without echocardiography were followed for 6 months in order to confirm or reject possible IE.

RESULTS

The study included 585 patients with Gram positive cocci bacteremia, and echocardiography was performed in 414 (71%) of them. The prevalence of IE in patients with high risk bacteremia, i.e. Staphylococcus aureus, non-beta-hemolytic streptococci, Enterococcus faecalis, and coagulase-negative staphylococci was 16%. Patients with Enterococcus faecalis had the highest prevalence of IE (33%) followed by non-beta-hemolytic streptococci (23%) and Staphylococcus aureus (12%). Among low risk bacteremia the prevalence of IE was 1%. The mean age of patients with IE was 74 years (SD 12.9) and 71% were male.

CONCLUSION

These findings strongly support routine echocardiography in patients with high risk bacteremia and non-performance of echocardiography in patients with low risk bacteremia.

EACVI survey on standardization of cardiac chambers quantification by transthoracic echocardiography

AIMS

To evaluate standard reporting of cardiac chambers size and function by transthoracic echocardiography (TTE), the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of three-dimensional echocardiography (3DE) and speckle tracking-derived myocardial deformation imaging (STE) was explored.

METHODS AND RESULTS

A total of 96 European Echocardiography Laboratories from 22 different countries responded to the survey, which consisted of 20 questions. For most of the standard parameters of cardiac chamber size and function, answers from the centres were homogeneous and demonstrated good adherence to current recommendations. In particular, all centres assessed left ventricular (LV) and left atrial (LA) size combining diameter measurements with volumes obtained using the bi-plane Simpson's method. More variability was observed in the measurements of the right heart chambers and thoracic aorta. Interestingly, >90% of centres had access to 3DE and STE; however, the large majority of centres reserved the use of these techniques for selected cases, particularly for the measure of 3D LV volumes and ejection fraction and global longitudinal strain in patients being considered for cardiac device implantation, surgical intervention (valvular heart disease) or screened for cardiotoxicity. Only 10% of centres used 3DE for right ventricular and LA volumes. Also, <30% of the centres used LA strain imaging.

CONCLUSION

In Europe, a good adherence to current recommendations was observed for most of the standard parameters of cardiac chambers quantification by TTE. Advanced echocardiography modalities, such as 3DE and STE, are widely available but used only in selected cases.

[Perforated posterior mitral valve aneurysm: a rare complication of infective endocarditis: a case report]

Mitral valve aneurysm is a rare abnormality whose pathophysiology is poorly understood. It is defined as a bulge of the mitral valve leaflet toward the left atrium. Aneurysm in the posterior leaflet is exceptional. We report the case of a 26-year old man, who had been followed up for rheumatic aortic regurgitation for 4-years, hospitalized for febrile syndrome associated with episodes of left heart failure. Transthoracic echocardiographic examination (TTE) and transesophageal echocardiography (TEE) showed aortic valve vegetations with wide aneurysm of the small mitral valve associated with severe mitral valve regurgitation. The patient underwent mitral and aortic valve replacement with simple postoperative outcome. Clinical suspicion associated with suitable preoperative imaging and early surgical treatment are essential to recognize and treat this rare complication of infectious endocard.

Rare Simultaneous Left and Right-Sided Native Valve Infective Endocarditis Caused by Rare Bacterium

Simultaneous left and right-sided native valve infective endocarditis (IE) is rare. Staphylococcus aureus was the predominant organism for bilateral IE. Shunt diseases are common risk factors of both-sided IE. Streptococcus anginosus (S. anginosus) is usually associated with pyogenic infections, but rarely a cause of IE. Here we present an extremely rare case of simultaneous left and right-sided native valve IE affecting the mitral and tricuspid valves caused by S. anginosus in an adult patient that has not been reported in the literature previously, particularly without the most frequent predisposing factors of IE. A 66-year-old man was admitted due to generalized fatigue, chills, malaise, and intermittent fevers for 1 year. A grade III-IV/VI systolic murmur at the mitral area and a III/VI systolic murmur at the tricuspid area were noted on physical examination. Laboratory evaluation revealed an elevated erythrocyte sedimentation rate and C-reactive protein level, and high fasting blood glucose. Blood culture was positive for S. anginosus. Echocardiography revealed vegetations in both sides of the heart: a large mitral valve vegetation with severe mitral regurgitation, as well as another vegetation on the tricuspid valve with moderate regurgitation. The case highlights a rare pathogen of both-sided IE, a rare presentation of S. anginosus infection, and several points worthy of note in echocardiography of IE.

Heartbreak: A case of post-infarction cardiogenic shock

Ventricular septal rupture is a rare but catastrophic complication of acute myocardial infarction. Although it has declined in incidence since the introduction of percutaneous coronary intervention, there hasn't been a significant change of mortality from the condition. In the chain of survival, prompt diagnosis and definitive surgery form the cardinal links. Prolonged medical management is not a feasible option as it is likely to be futile but the aim should be to reduce afterload with the help of intra-aortic balloon pump or support with ventricular assist devices. Echocardiography sits at the heart of the diagnosis of this time critical condition and will guide accurate therapy and intervention. We present the first reported case from an Australian emergency department, where the echocardiography done by the emergency physician clinched the diagnosis. We emphasise here the paramountcy of emergency physicians being proficient in basic echocardiography to achieve rapid diagnosis. Once diagnosed it is critical to have an individual case-tailored multi-disciplinary discussion between emergency medicine, cardiothoracic surgery, cardiology and intensive care as to plan the optimal timing of surgery.

L-Menthol mouth rinse or ice slurry ingestion during the latter stages of exercise in the heat provide a novel stimulus to enhance performance despite elevation in mean body temperature

Purpose

This study investigated the effects of l-menthol mouth rinse and ice slurry ingestion on time to exhaustion, when administered at the latter stages (~ 85%) of baseline exercise duration in the heat (35 °C).

Method

Ten male participants performed four time to exhaustion (TTE) trials on a cycle ergometer at 70% W_max. In a randomized crossover design, (1) placebo-flavored non-calorific mouth rinse, (2) l-menthol mouth rinse (0.01%), or (3) ice ingestion (1.25 g kg⁻¹), was administered at 85% of participants’ baseline TTE. Time to exhaustion, core and skin temperature, heart rate, rating of perceived effort, thermal comfort and thermal sensation were recorded.

Results

From the point of administration at 85% of baseline TTE, exercise time was extended by 1% (placebo, 15 s), 6% (l-menthol, 82 s) and 7% (ice, 108 s), relative to baseline performance (P = 0.036), with no difference between l-menthol and ice (P > 0.05). Core temperature, skin temperature, and heart rate increased with time but did not differ between conditions (P > 0.05). Thermal sensation did not differ significantly but demonstrated a large effect size (P = 0.080; \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\eta _{{\text{p}}}^{2}$$\end{document}ηp2 = 0.260).

Conclusion

These results indicate that both thermally cooling and non-thermally cooling oral stimuli have an equal and immediate behavioral, rather than physiological, influence on exhaustive exercise in the heat.

A Rare Case of a Giant Coronary Sinus with Focal Aneurysm Secondary to Multiple Fistulous Connections Arising from a Dilated, Tortuous Left Circumflex Coronary Artery

•TTE adds value in the diagnosis of a coronary artery-to-coronary sinus fistula. •AV fistula was observed via two connections between the LCx and coronary sinus. •Multimodality imaging aids in the diagnosis of coronary artery fistula.

Multi-view approach for the diagnosis of pulmonary hypertension using transthoracic echocardiography

Pulmonary hypertension (PH) is a disease with severe morbidity and mortality. Echocardiography plays an essential role in the screening of PH. The quality of the acquired continuous wave Doppler signal is the major limitation of the method and can greatly affect the accuracy of estimated pulmonary pressures. The aim of this study was to evaluate the clinical need to image from multiple ultrasound windows in patients with suspected pulmonary hypertension. We prospectively evaluated 65 patients (43% male, mean age 67.2 years) with echocardiography and right heart catheterization. 17% had invasively normal pulmonary pressures, 83% had pulmonary hypertension. Peak tricuspid regurgitation (TR) velocity was imaged in five echocardiographic views. Sufficient Doppler signal was recorded in 94% of the patients. Correlation for overall peak TR velocity with invasively measured systolic pulmonary artery pressure was r = 0.83 (p < 0.001). Considering all five imaging windows resulted in a sensitivity of 87%, and a specificity of 91% for correct diagnosis of PH with an AUC of 0.89, which was significantly better as compared to sole imaging from the right ventricular modified apical four-chamber view (AUC 0.85, p = 0.0395). Additional imaging from atypical views changed the overall peak TR velocity in 32% of the patients. A multiple-view approach changed the echocardiographic diagnosis of PH in 11% of the patients as opposed to sole imaging from an apical four-chamber view. This study comprehensively assessed the impact on clinical decision making when evaluating patients with an echocardiographic multiplane approach for suspected PH. This approach substantially increased sensitivity without a decrease in specificity.

Imaging manifestations of Behcet's disease: Key considerations and major features

Behcet's disease is an autoimmune disease most commonly seen in the Middle East. Although primarily known with painful oral and genital ulcers, it can lead to vasculitis. Therefore, several associated complications such as thrombotic syndromes, aneurysmal arterial disease may arise. In many cases, it might be difficult to make the diagnosis purely based on clinical grounds; however, imaging plays an important role for both diagnosis and assessment of the disease's complications. We provide a comprehensive review of the most notable imaging findings of Behcet's disease.

Epicardial Adipose Tissue Thickness and Its Association With the Presence and Severity of Coronary Artery Disease in Clinical Setting: A Cross-Sectional Observational Study

Background

Obesity is an important risk factor for atherosclerotic cardiovascular disease (ASCVD). Estimation of visceral adipose tissue is important and several methods are available as its surrogate. Although correlation of epicardial adipose tissue (EAT) with visceral adipose tissue as estimated by magnetic resonance imaging (MRI) and/or CT is excellent, it is costlier and cumbersome. EAT can be accurately measured by two-dimensional (2D) echocardiography. It tends to be higher in patients with acute coronary syndrome than in subjects without coronary artery disease (CAD) and in those with stable angina. It also carries advantage as index of high cardiometabolic risk as it is a direct measure of visceral fat rather than anthropometric measurements. The present study evaluated the relationship of EAT to the presence and severity of CAD in clinical setting.

Methods

In this prospective, single-center study conducted in the Department of Cardiology, LPS Institute of Cardiology, Kanpur, India, 549 consecutive patients with acute coronary syndrome or chronic stable angina were enrolled. Sensitivity, specificity, and receiver operating characteristic (ROC) curve were estimated to find cut-off value of EAT thickness for diagnosing CAD using coronary angiographic findings as gold standard.

Results

Patients were diagnosed as CAD group (n = 464, 60.30 ± 8.36 years) and non-CAD group (n = 85, 54.42 ± 11.93 years) after assessing coronary angiograms. The EAT was measured at end-systole from the PLAX views of three cardiac cycles on the free wall of the right ventricle. Lesion was significant if > 50% in left main and > 70% in other coronary arteries. The mean EAT thickness in CAD group was 5.10 ± 1.06 and in non-CAD group was 4.36 ± 1.01 which was significant (P = 0.003). Significant correlation was demonstrated between EAT thickness and presence of CAD (P < 0.003). Higher EAT was associated with severe CAD and presence of multivessel disease. By ROC analysis, EAT > 4.65 mm predicated the presence of significant coronary stenosis by 71.6% sensitivity and 73.1% specificity.

Conclusion

EAT thickness measured using transthoracic echocardiography (TTE) significantly correlates with the presence and severity of CAD. It is sensitive, easily available, and cost-effective and assists in the risk stratification and may be an additional marker on classical risk factors for CAD.

Intracardiac echocardiography during atrial septal defect and patent foramen ovale device closure in pediatric and adolescent patients

BACKGROUND

Intracardiac echocardiography (ICE) is commonly used during interventional cardiac catheterization in adults, but data regarding the use of ICE in children are limited. There are no data available comparing the effectiveness of preprocedural transthoracic echocardiography (TTE) with that of intraprocedural ICE in predicting atrial septal defect (ASD) size and rim adequacy for percutaneous closure in a pediatric population. The objectives of this study were to describe the investigators' experience using ICE in pediatric and adolescent patients and to compare the effectiveness of preprocedural TTE with that of ICE in predicting ASD size and rim adequacy for percutaneous closure.

METHODS

In this retrospective study, all cases in which ICE was used during ASD or patent foramen ovale closure in patients ≤21 years of age at a single institution from January 2002 through October 2013 were reviewed. All studies were performed using the Acuson AcuNav ICE system.

RESULTS

One hundred fifteen patients (65 female; mean age, 12 ± 6 years; range, 10 months to 21 years) were included. All intracardiac echocardiographic studies were performed by the interventional cardiologist performing the catheterization. ICE was used to facilitate ASD closure in 92 patients (81%) and patent foramen ovale closure in 23 (19%). Thirty-eight patients (34%) underwent cardiac catheterization and ICE without general anesthesia. ICE was correlated highly with preprocedural TTE in predicting ASD size (r(2) = 0.76, P < .0001). In nine of 92 patients (9.8%) with ASDs, ICE identified deficient septal rims (n = 8) or complex or multiple ASDs (n = 1) that necessitated surgical closure. There were no major complications.

CONCLUSIONS

ICE can be performed safely and effectively in a large cohort of children and adolescents undergoing percutaneous device closure. ICE may obviate the need for general anesthesia in some patients and is a reasonable alternative to transesophageal echocardiography for this catheter-based procedure in children. ASD measurements with ICE correlate well with preprocedural measurements on TTE; however, ICE more accurately identifies the absence or deficiency of critical septal rims before device closure.

Libman-Sacks endocarditis and embolic cerebrovascular disease

OBJECTIVES

The aim of this study was to determine whether Libman-Sacks endocarditis is a pathogenic factor for cerebrovascular disease (CVD) in systemic lupus erythematosus (SLE).

BACKGROUND

A cardioembolic pathogenesis of SLE CVD manifested as: 1) neuropsychiatric systemic lupus erythematosus (NPSLE), including stroke and transient ischemic attacks (TIA); 2) neurocognitive dysfunction; and 3) magnetic resonance imaging of focal brain lesions has not been established.

METHODS

A 6-year study of 30 patients with acute NPSLE (27 women, 38 ± 12 years of age), 46 age- and sex-matched SLE controls without NPSLE (42 women, 36 ± 12 years of age), and 26 age- and sex-matched healthy controls (22 women, 34 ± 11 years of age) who underwent clinical and laboratory evaluations, transesophageal echocardiography, carotid duplex ultrasound, transcranial Doppler ultrasound, neurocognitive testing, and brain magnetic resonance imaging/magnetic resonance angiography. Patients with NPSLE were re-evaluated after 4.5 months of therapy. All patients were followed clinically for a median of 52 months.

RESULTS

Libman-Sacks vegetations (87%), cerebromicroembolism (27% with 2.5 times more events per hour), neurocognitive dysfunction (60%), and cerebral infarcts (47%) were more common in NPSLE than in SLE (28%, 20%, 33%, and 0%) and healthy controls (8%, 0%, 4%, and 0%, respectively) (all p ≤ 0.009). Patients with vegetations had 3 times more cerebromicroemboli per hour, lower cerebral blood flow, more strokes/TIA and overall NPSLE events, neurocognitive dysfunction, cerebral infarcts, and brain lesion load than those without (all p ≤ 0.01). Libman-Sacks vegetations were independent risk factors of NPSLE (odds ratio [OR]: 13.4; p < 0.001), neurocognitive dysfunction (OR: 8.0; p = 0.01), brain lesions (OR: 5.6; p = 0.004), and all 3 outcomes combined (OR: 7.5; p < 0.001). Follow-up re-evaluations in 18 of 23 (78%) surviving patients with NPSLE demonstrated improvement of vegetations, microembolism, brain perfusion, neurocognitive dysfunction, and lesion load (all p ≤ 0.04). Finally, patients with vegetations had reduced event-free survival time to stroke/TIA, cognitive disability, or death (p = 0.007).

CONCLUSIONS

The presence of Libman-Sacks endocarditis in patients with SLE was associated with a higher risk for embolic CVD. This suggests that Libman-Sacks endocarditis may be a source of cerebral emboli.

Pretest probability of a normal echocardiography: validation of a simple and practical algorithm for routine use

BACKGROUND

Management of increased referrals for transthoracic echocardiography (TTE) examinations is a challenge. Patients with normal TTE examinations take less time to explore than those with heart abnormalities. A reliable method for assessing pretest probability of a normal TTE may optimize management of requests.

AIM

To establish and validate, based on requests for examinations, a simple algorithm for defining pretest probability of a normal TTE.

METHODS

In a retrospective phase, factors associated with normality were investigated and an algorithm was designed. In a prospective phase, patients were classified in accordance with the algorithm as being at high or low probability of having a normal TTE.

RESULTS

In the retrospective phase, 42% of 618 examinations were normal. In multivariable analysis, age and absence of cardiac history were associated to normality. Low pretest probability of normal TTE was defined by known cardiac history or, in case of doubt about cardiac history, by age>70 years. In the prospective phase, the prevalences of normality were 72% and 25% in high (n=167) and low (n=241) pretest probability of normality groups, respectively. The mean duration of normal examinations was significantly shorter than abnormal examinations (13.8 ± 9.2 min vs 17.6 ± 11.1 min; P=0.0003).

CONCLUSION

A simple algorithm can classify patients referred for TTE as being at high or low pretest probability of having a normal examination. This algorithm might help to optimize management of requests in routine practice.

Myocardial dysfunction in pediatric septic shock

OBJECTIVE

To evaluate the prevalence and significance of myocardial dysfunction in children with septic shock.

STUDY DESIGN

Thirty patients with septic shock were evaluated by transthoracic echocardiography within 24 hours of admission to a pediatric critical care unit. Transthoracic echocardiography evaluation included left ventricular (LV) size and function, mitral valve inflow velocities in early and late diastole, mitral valve annular velocities in systole and early and late diastole, and LV myocardial performance index. LV systolic dysfunction was defined as an ejection fraction or shortening fraction z-score <-2, and LV diastolic dysfunction was defined as a mitral valve inflow velocity/annular velocity in early diastole ratio z-score >2. Secondary outcomes included troponin I concentration, acute kidney injury, and 28-day mechanical ventilation-free duration.

RESULTS

Mortality for the 30 patients (mean age, 9.5 ± 7 years) was 7%. The prevalence of LV systolic and/or diastolic dysfunction was 53% (16 of 30). Eleven patients (37%) had systolic dysfunction, 10 (33%) had diastolic dysfunction, and 5 (17%) had both. Systolic and/or diastolic dysfunction was significantly associated with troponin I level (P = .007) and acute kidney injury (P = .02), but not with ventilation-free duration (P = .12). Kaplan-Meier analyses for pediatric critical care unit and hospital length of stay identified no differences between patients with and those without myocardial dysfunction.

CONCLUSION

Myocardial dysfunction occurs frequently in children with septic shock but might not affect hospital length of stay.

Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement

OBJECTIVE

The study objective was to determine whether recurrent or residual mild aortic regurgitation, which occurs after valve-sparing aortic root replacement, progresses over time.

METHODS

Between 2003 and 2008, 154 patients underwent Tirone David-V valve-sparing aortic root replacement; 96 patients (62%) had both 1-year (median, 12 ± 4 months) and mid-term (62 ± 22 months) transthoracic echocardiograms available for analysis. Age of patients averaged 38 ± 13 years, 71% were male, 31% had a bicuspid aortic valve, 41% had Marfan syndrome, and 51% underwent aortic valve repair, predominantly cusp free margin shortening.

RESULTS

Forty-one patients (43%) had mild aortic regurgitation on 1-year echocardiogram. In 85% of patients (n = 35), mild aortic regurgitation remained stable on the most recent echocardiogram (median, 57 ± 20 months); progression to moderate aortic regurgitation occurred in 5 patients (12%) at a median of 28 ± 18 months and remained stable thereafter; severe aortic regurgitation developed in 1 patient, eventually requiring reoperation. Five patients (5%) had moderate aortic regurgitation at 1 year, which did not progress subsequently. Two patients (2%) had more than moderate aortic regurgitation at 1 year, and both ultimately required reoperation.

CONCLUSIONS

Although mild aortic regurgitation occurs frequently after valve-sparing aortic root replacement, it is unlikely to progress over the next 5 years and should not be interpreted as failure of the valve-preservation concept. Further, we suggest that mild aortic regurgitation should not be considered nonstructural valve dysfunction, as the 2008 valve reporting guidelines would indicate. We need 10- to 15-year follow-up to learn the long-term clinical consequences of mild aortic regurgitation early after valve-sparing aortic root replacement.

Mitral inflow patterns after MitraClip implantation at rest and during exercise

BACKGROUND

MitraClip implantation reduces mitral regurgitation effectively but decreases mitral valve area, creating iatrogenic mitral stenosis. Evaluation with transesophageal echocardiography intraprocedurally is necessary to measure mitral regurgitation and mitral valve pressure gradient (MVPG) to determine whether it is necessary and safe to place more clips. The aim of this study was to investigate whether these intraprocedural hemodynamics represent postprocedural measurements and whether exercise is affected by the stenosis.

METHODS

In this retrospective single-center study, 51 patients who underwent MitraClip implantation were included. Measurements were performed intraprocedurally using transesophageal echocardiography and postprocedurally using transthoracic echocardiography. In 23 of these patients, exercise echocardiography was performed at follow-up.

RESULTS

Intraprocedural mean MVPG was 3.0 ± 1.6 mm Hg and increased to 4.3 ± 2.2 mm Hg postprocedurally (P < .001). During exercise, mean MVPG increased significantly compared with rest conditions (from 3.6 ± 1.7 to 6.3 ± 2.7 mm Hg, P < .001). Six patients had mean resting MVPGs ≥ 5 mm Hg at follow-up and had higher systolic pulmonary artery pressure (sPAPs) than patients with mean MVPGs < 5 mm Hg (47 ± 7 vs 35 ± 12 mm Hg, P = .035). Higher MVPG and sPAP did not lead to more symptoms of heart failure. Receiver operating characteristic curve analysis showed an estimated cutoff point for intraprocedural pressure half-time of 91 msec to identify patients with mitral stenosis and sPAP ≥ 50 mm Hg postprocedurally.

CONCLUSIONS

Mean MVPG during MitraClip implantation measured by TEE underestimates the hemodynamics in daily life, of which operators should be aware when deciding on placing one or more clips. Pressure half-time seems to be the most robust parameter compared with mean and maximum MVPG and may contribute to this decision. Patients with higher mean MVPGs after MitraClip implantation have higher sPAPs at follow-up. However, more symptoms of heart failure were not detected at follow-up.

Cardiac amyloidosis: updates in diagnosis and management

Amyloidosis is a severe systemic disease. Cardiac involvement may occur in the three main types of amyloidosis (acquired monoclonal light-chain, hereditary transthyretin and senile amyloidosis) and has a major impact on prognosis. Imaging the heart to characterize and detect early cardiac involvement is one of the major aims in the assessment of this disease. Electrocardiography and transthoracic echocardiography are important diagnostic and prognostic tools in patients with cardiac involvement. Cardiac magnetic resonance imaging better characterizes myocardial involvement, functional abnormalities and amyloid deposition due to its high spatial resolution. Nuclear imaging has a role in the diagnosis of transthyretin amyloid cardiomyopathy. Cardiac biomarkers are now used for risk stratification and staging of patients with light-chain systemic amyloidosis. Different types of cardiac complications may occur, including diastolic followed by systolic heart failure, atrial and/or ventricular arrhythmias, conduction disturbances, embolic events and sometimes sudden death. Senile amyloid and hereditary transthyretin amyloid cardiomyopathy have better prognoses than light-chain amyloidosis. Cardiac treatment of heart failure is usually ineffective and is often poorly tolerated because of its hypotensive and bradycardiac effects. The three main types of amyloid disease, despite their similar cardiac appearance, have specific new aetiological treatments that may change the prognosis of this disease. Cardiologists should be aware of this disease to allow early treatment.

Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification

BACKGROUND

The two-dimensional (2D) proximal isovelocity surface area (PISA) method has known technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions and has already been validated for mitral regurgitation assessment. The aim of this study was to apply this novel method in patients with chronic tricuspid regurgitation (TR).

METHODS

Ninety patients with chronic TR were enrolled. EROA and regurgitant volume (Rvol) were assessed using transthoracic 2D and 3D PISA methods. Quantitative Doppler and 3D transthoracic planimetry of EROA were used as reference methods.

RESULTS

Both EROA and Rvol assessed using the 3D PISA method had better correlations with the reference methods than using conventional 2D PISA, particularly in the assessment of eccentric jets. On the basis of 3D planimetry-derived EROA, 35 patients had severe TR (EROA ≥ 0.4 cm(2)). Among these 35 patients, 25.7% (n = 9) were underestimated as having nonsevere TR (EROA ≤ 0.4 cm(2)) using the 2D PISA method. In contrast, the 3D PISA method had 94.3% agreement (33 of 35) with 3D planimetry in classifying severe TR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.92 and 0.88 respectively.

CONCLUSIONS

TR quantification using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Three-dimensional modeling of the right ventricle from two-dimensional transthoracic echocardiographic images: utility of knowledge-based reconstruction in pulmonary arterial hypertension

BACKGROUND

Right ventricular (RV) volume and functional assessments are essential in the management of pulmonary arterial hypertension but are often difficult to perform. Three-dimensional (3D) echocardiography is limited by acoustic dropout of the RV free wall in dilated ventricles. The aim of this study was to test the hypothesis that knowledge-based reconstruction, a novel method for 3D modeling of RV endocardium from two-dimensional echocardiographic images, could provide accurate measurements of RV volumes and systolic function.

METHODS

Twenty-seven patients with pulmonary arterial hypertension were prospectively recruited for same-day echocardiography and cardiovascular magnetic resonance (CMR), which was used as a reference standard. Two-dimensional transthoracic echocardiographic images were acquired with 3D spatial localization equipment to allow 3D reconstruction. Image analysis was performed with dedicated software to obtain end-diastolic volume (EDV) and end-systolic volume (ESV) and RV ejection fraction (EF). The method of disks was used to determine RV volumes on CMR.

RESULTS

Echocardiographic RV volumes correlated well with CMR (EDV, R = 0.87; ESV, R = 0.88; EF, R = 0.75). For interobserver analyses, coefficients of variability were 7.8 ± 7.0% for EDV, 10.2 ± 8.0% for ESV, and 15.4 ± 13.8% for EF. For intraobserver analyses, coefficients of variability were 7.1 ± 5.1% for EDV, 8.3 ± 7.0% for ESV, and 10.9 ± 9.2% for EF. On Bland-Altman analyses, volumes obtained on transthoracic echocardiography (TTE) were slightly larger than those obtained by CMR (ΔEDVTTE-CMR, 5.8 ± 33.7 mL; ΔESVTTE-CMR, 3.5 ± 27.8 mL), whereas EFs tended to be slightly higher by CMR (ΔEFCMR-TTE, 0.5 ± 6.5%).

CONCLUSIONS

Knowledge-based reconstruction provides accurate and reproducible measurements of RV volumes in patients with pulmonary arterial hypertension. Larger studies are needed to confirm these results and to determine the practicality of this approach in daily practice and as an end point in clinical trials.

Can we talk? Reflections on effective communication between imager and interventionalist in congenital heart disease

The rapid proliferation of catheter-mediated treatments for congenital heart defects has brought with it a critical need for cooperation and communication among the numerous physicians supporting these new and complex procedures. New interdependencies between physicians in specialties including cardiac imaging, interventional cardiology, pediatric cardiology, anesthesia, cardiothoracic surgery, and radiology have become apparent, as centers have strived to develop the best systems to foster success. Best practices for congenital heart disease interventions mandate confident and timely input from an individual with excellent adjunctive imaging skills and a thorough understanding of the devices and procedures being used. The imager and interventionalist must share an understanding of what each offers for the procedure, use a common terminology and spatial orientation system, and convey concise and accurate information about what is needed, what is seen, and what cannot be seen. The goal of this article is to review how the cardiovascular imaging specialists and interventionalists can work together effectively to plan and execute catheter interventions for congenital heart disease.

Prosthesis sizing for transcatheter aortic valve implantation--comparison of three dimensional transesophageal echocardiography with multislice computed tomography

BACKGROUND

The complex anatomy of the aortic annulus warrants the use of three dimensional (3D) modalities for prosthesis sizing in transcatheter aortic valve implantation (TAVI). Multislice computed tomography (MSCT) has been used for this purpose, but its use may be restricted because of contrast administration. 3D transesophageal echocardiography (3D-TEE) lacks this limitation and data on comparison with MSCT is scarce. We compared 3D-TEE with MSCT for prosthesis sizing in TAVI.

METHODS

Aortic annulus diameters in the sagittal and coronal plane and annulus areas in 3D-TEE and MSCT were compared in 57 patients undergoing TAVI. Final prosthesis size was left at the operator's discretion and the agreement with 3D-TEE and MSCT was calculated.

RESULTS

Sagittal diameters on 3D-TEE and MSCT correlated well (r=.754, p<.0001) and means were comparable (22.3±2.1 vs. 22.5±2.3 mm; p=0.2; mean difference: -0.3 mm [-3.3-2.8]). On 3D-TEE, coronal diameter and annulus area were significantly smaller (p<.0001 for both) with moderate correlation (r=0.454 and r=0.592). Interobserver variability was comparable for both modalities. TAVI was successful in all patients with no severe post-procedural insufficiency. Final prosthesis size was best predicted by sagittal annulus diameters in 84% and 79% by 3D-TEE and MSCT, respectively. Agreement between both modalities was 77%.

CONCLUSIONS

Annulus diameters and areas for pre-procedural TAVI assessment by 3D-TEE are significantly smaller than MSCT with exception of sagittal diameters. Using sagittal diameters, both modalities predicted well final prosthesis size and excellent procedural results were obtained. 3D-TEE can thus be a useful alternative in patients with contraindications to MSCT.

Ventricular hypertrophy and left atrial dilatation persist and are associated with reduced survival after valve replacement for aortic stenosis

OBJECTIVES

We sought to understand the factors modulating left heart reverse remodeling after aortic valve replacement, the relationship between the preoperative symptoms and modulators of left heart remodeling, and their influence on long-term survival.

METHODS

From October 1991 to January 2008, 4264 patients underwent primary aortic valve replacement for aortic stenosis. Changes in the time course of left ventricular reverse remodeling were assessed using 5740 postoperative transthoracic echocardiograms from 3841 patients.

RESULTS

Left ventricular hypertrophy rapidly declined after surgery, from 137 ± 42 g/m(2) preoperatively to 115 ± 27 by 2 years and remained relatively constant but greater than the upper limit of normal. The most important risk factor for residual left ventricular hypertrophy was greater preoperative left ventricular hypertrophy (P < .0001). Other factors included a greater left atrial diameter (reflecting diastolic dysfunction), a lower ejection fraction, and male gender. An increased postoperative transprosthesis gradient was associated with greater residual left ventricular hypertrophy; however, its effect was minimal. Preoperative severe left ventricular hypertrophy and left atrial dilatation reduced long-term survival, independent of symptom status.

CONCLUSIONS

Severe left ventricular hypertrophy with left atrial dilatation can develop from severe aortic stenosis, even without symptoms. These changes can persist, are associated with decreased long-term survival even after successful aortic valve replacement, and could be indications for early aortic valve replacement if supported by findings from an appropriate prospective study.

Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure

OBJECTIVES

To study the effect of mitral valve repair with or without concomitant tricuspid valve repair on functional tricuspid regurgitation and right ventricular function.

METHODS

From 2001 to 2007, 1833 patients with degenerative mitral valve disease, a structurally normal tricuspid valve, and no coronary artery disease underwent mitral valve repair, and 67 underwent concomitant tricuspid valve repair. Right ventricular function (myocardial performance index and tricuspid annular plane systolic excursion) was measured before and after surgery using transthoracic echocardiography for randomly selected patients with tricuspid regurgitation grade 0, 1+, and 2+ (100 patients for each grade) and 93 with grade 3+/4+, 393 patients in total.

RESULTS

In patients with mild (<3+) preoperative tricuspid regurgitation, mitral valve repair alone was associated with reduced tricuspid regurgitation and mild worsening of right ventricular function. Tricuspid regurgitation of 2+ or greater developed in fewer than 20%, and right ventricular function had improved, but not to preoperative levels, at 3 years. In patients with severe (3+/4+) preoperative tricuspid regurgitation, mitral valve repair alone reduced tricuspid regurgitation and improved right ventricular function; however, tricuspid regurgitation of 2+ or greater returned and right ventricular function worsened toward preoperative levels within 3 years. Concomitant tricuspid valve repair effectively eliminated severe tricuspid regurgitation and improved right ventricular function. Also, over time, tricuspid regurgitation did not return and right ventricular function continued to improve to levels comparable to that of patients with lower grades of preoperative tricuspid regurgitation.

CONCLUSIONS

In patients with mitral valve disease and severe tricuspid regurgitation, mitral valve repair alone was associated with improved tricuspid regurgitation and right ventricular function. However, the improvements were incomplete and temporary. In contrast, concomitant tricuspid valve repair effectively and durably eliminated severe tricuspid regurgitation and improved right ventricular function toward normal, supporting an aggressive approach to important functional tricuspid regurgitation.