Novel 3D versus traditional transesophageal echocardiography techniques: Defining differences in the diagnosis of infective endocarditis

BACKGROUND

Despite the availability of current antibiotic and surgical treatment options, infective endocarditis (IE) remains associated with a high mortality rate. Even though two-dimensional (2D) transesophageal echocardiography (TOE) is a major criteria in the diagnosis of IE, it is constrained by the single-plane orientation. Since three-dimensional (3D) TOE provides a comprehensive understanding of the cardiac architecture by allowing for a realistic visualization of the underlying structures in 3D space, it has attracted considerable interest in recent years.

AIM

The purpose of this narrative review is to discuss the advantages and pitfalls of 3D TOE in patients with IE, as well as to address emerging photo-realistic 3D techniques that have the potential to enhance the visualization of cardiac structures in this setting.

RESULTS

According to recent research, 3D TOE acquisitions outperform 2D acquisitions in terms of vegetation identification accuracy and embolism risk assessment. By reporting a variety of findings that are missed with 2D TOE, but which are validated by surgical examination, 3D TOE further improves the ability to identify endocarditis complications on both native and prosthetic valves. In addition to conventional 3D TOE, future developments in 3D technology led to the development of transillumination and tissue-transparency rendering, which may improve anatomical understanding and depth perception. Due to the use of both conventional and novel 3D techniques, there are more patients who require surgical intervention, indicating that 3D TOE may have a clinical relevance on the surgical management.

CONCLUSION

3D TOE might fill the gaps left by 2D TOE in the diagnosis of IE.

The Role of Multimodality Imaging in the Diagnosis and Follow-Up of Malignant Primary Cardiac Tumors: Myxofibrosarcoma-A Case Report and Literature Review

Cardiac tumors are a very rare but heterogenous group of diseases that may reveal themselves through a variety of nonspecific cardiac symptoms that may pose a challenge to the diagnostic process. Myxofibrosarcoma is a particularly rare type of cardiac tumor that carries a poor prognosis, thus making accurate and timely diagnosis essential. A 61-year-old woman presented with fatigue and shortness of breath during mild exercise, symptoms that have progressively worsened during the previous year. Multimodality imaging consisting of transthoracic and transesophageal echocardiography (TTE and TEE), cardiac magnetic resonance (CMR), cardiac computer tomography (CCT), and fluorodeoxyglucose positron emission computer tomography (18F-FDG PET-CT) was used for the diagnosis and postoperative follow-up of a myxofibrosarcoma.

The Degree of Stent Apposition Measured by Stent Enhancement at the Level of the Side Branch as a Novel Predictor of Procedural Success in Left Main PCI

BACKGROUND

Stent enhancement techniques allow adequate visualization of stent deformation or incomplete stent expansion at the ostium of the side branch. Measuring the stent enhancement side branch length (SESBL) could reflect procedural success in terms of optimal stent expansion and apposition with better long-term outcomes. A longer SESBL may reflect a better stent apposition at the polygon of confluence and at the side branch (SB) ostium.

METHODS

We evaluated 162 patients receiving the left main (LM) provisional one-stent technique and measured the SESBL, dividing them into two groups: SESBL≤ 2.0 mm and SESBL > 2.0 mm.

RESULTS

The mean SESBL was 2.0 ± 1.2 mm. More than half of the bifurcations had both main and side branch lesions (Medina 1-1-1) (84 patients, 51.9%) and the length of the SB disease was 5.2 ±1.8 mm. Kissing balloon inflation (KBI) was performed in 49 patients (30.2%). During follow-up (12 months), there was a significantly higher rate of cardiac death in the SESBL ≤ 2.0 mm group (p = 0.02) but no significant difference in all major adverse cardiovascular events (MACEs) (p = 0.7). KBI did not influence the outcomes (p = 0.3).

CONCLUSION

Suboptimal SESBL is positively correlated with worse outcomes and SB compromise. This novel sign could aid the LM operator to assess the level of stent expansion at the ostium of the SB in the absence of intracoronary imaging.

Clinical Characteristics and Outcomes following Percutaneous Coronary Intervention in Unprotected Left Main Disease: A Single-Center Study

Background: Hemodynamically significant unprotected left main (LM) coronary artery disease is a high-risk clinical condition because of the large area of myocardium at risk, and it requires prompt revascularization. Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected LM disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG after adequate counseling by the heart team. Methods: We retrospectively evaluated 201 patients receiving left main (LM) provisional one-stent or two-stent procedures, and we assessed the clinical characteristics and outcomes of patients undergoing unprotected LM PCI. Results: The mean age was 66.5 ± 9.9 years, and 72% were male. The majority of the subjects presented several cardiovascular risk factors, among which arterial hypertension (179 patients, 89.5%) and dyslipidemia (173 patients, 86.5%) were the most frequent. Out of all patients, 162 (81.8%) underwent revascularization by using the one-stent technique, while the two-stent technique was used in 36 patients (18.2%). The median value of fractional flow reserve (FFR) of the side branch was 0.9 [0.85–0.95], and 135 patients (67.1%) showed a value of FFR > 0.8. One hundred nine patients (54.2%) had a stent enhancement side branch length (SESBL) > 2, with median values of 2.5 mm2 [2.1–3]. Regarding angiographic parameters, the LM area as assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and the grade of stenosis as assessed by quantitative coronary angiography (QCA) were similar between groups. However, patients who required revascularization by using the two-stent technique presented more frequently with intermediate rather than low SYNTAX scores (69.4% vs. 28.4%, p < 0.0001). Also, the same group required kissing balloon inflation (KBI) more frequently (69.4% vs. 30%, p < 0.001). There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique. FFR was able to predict a SESBL > 2 mm. The cut-off value for FFR to afford the highest degree of sensitivity (74.5%) and specificity (47%) for a SESBL > 2 was >0.86, indicating a moderate accuracy (AUC = 0.61, 95% CI 0.525–0.690, p = 0.036). Conclusions: Unprotected left main PCI is a safe and effective revascularization option amongst a complex and morbid population. There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique, and there was no significant impact of KBI on side branch FFR measurements but lower side branch FFR values were correlated with angiographic side branch compromise.

The Role of Echocardiography in the Diagnosis of Cardiac Involvement in a Rare Systemic Condition: The Carcinoid Heart Disease: A Case Report and Review of Literature

Carcinoid heart disease is a rare presentation of the carcinoid syndrome, which is caused by excessive tumoral hormone production and the abundant release of vasoactive substances with systemic expressions. A 62-year-old woman presented with flushing, diarrhea, weight loss, and right-sided heart failure symptoms. Specific carcinoid heart disease features were identified using transthoracic and transesophageal echocardiography at the tricuspid and pulmonic valves. Biomarkers, 99mTc-Tektrotyd scintigraphy, SPECT-CT, and a biopsy later confirmed the diagnosis, and the patient began treatment for the underlying condition.

Imaging Challenges in the Diagnosis of Anatomical Variations of the Supra-Aortic Vessels: A Case Report and Review of Literature

A 73-year-old woman was referred to our Cardiology Department due to recurrent headaches and dizziness. She had a history of hypertension of 10 years. In the territorial hospital, left internal carotid artery significant stenosis was suspected. Neurological examination and laboratory tests were normal. A neck vascular ultrasound was performed, showing a low bifurcation of the left common carotid artery (CCA) and a hypoplastic left internal carotid artery (ICA) with a sinuous path at the cervical level. Therefore, a computed tomographic (CT) angiography examination of the head and neck vessels was performed. The images confirmed the presence of a hypoplastic left ICA, anatomic variation in the left CCA, and also showed that the left vertebral artery (VA) was stemming directly from the aortic arch, exhibiting a kinking trajectory.

Transthyretin cardiac amyloidosis

Transthyretin amyloid cardiomyopathy (ATTR-CM) may be an under recognized cause of heart failure (HF). TTR amyloidosis can be inherited, caused by variants in the TTR gene (ATTRv) or by deposition of wild-type TTR protein (ATTRwt), leading to high mortality if untreated. We report the case of a patient with hereditary TTR amyloidosis and mixed phenotype (both cardiac and neurological involvement). We highlight the importance of multimodal imaging in the evaluation of these patients, as early diagnosis and treatment might lead to better outcome.

Impact of Three-Dimensional Strain on Major Adverse Cardiovascular Events after Acute Myocardial Infarction Managed by Primary Percutaneous Coronary Intervention-A Pilot Study

Background: Three-dimensional speckle-tracking echocardiography (3D-STE) allows simultaneous assessment of multidirectional components of strain. However, there are few data on its usefulness to predict prognosis in patients with acute myocardial infarction (AMI). The objective of our pilot study was to evaluate the prognostic value of four different 3D-STE parameters (global longitudinal strain (GLS-3D), global circumferential strain (GCS-3D), global radial strain (GRS-3D), and global area strain (GAS)) in AMI, after successful revascularization by primary PCI. Methods: We enrolled 94 AMI patients (66 ± 13 years, 56% men) who underwent coronary angiography. All patients had been 3D-STE assessed and followed-up for 1 year for the occurrence of MACE. Results: A total of 25 MACE were recorded over follow-up. Cut-off values of −17% for GAS (HR = 3.1, 95% CI: 1.39–6.92, p = 0.005), −12% for GCS-3D (HR = 3.06, 95% CI: 1.36–6.8, p = 0.006), −10% for GLS-3D (HR = 3.04, 95% CI: 1.36–6.78, p = 0.006), and 25% for GRS-3D (HR = 2.89, 95% CI: 1.29–6.46, p = 0.009) showed moderate accuracy in MACE prediction. Multivariate regression showed that GAS (HR = 1.1, 95% CI: 1.03–1.16), GLS-3D (HR = 1.13, 95% CI: 1.03–1.26), and GCS-3D (HR = 1.13, 95% CI: 1.03–1.23) remained independent predictors of MACE (HR = 1.07, 95% CI: 1.01–1.14 for GAS, and HR = 1.1, 95% CI: 1.01–1.2 for GCS-3D). However, post hoc power analysis indicated adequate sample size (power of 80%) only for GAS and GCS-3D for the ROC curve analysis and for GAS, GCS-3D, and GRS-3D for the log-rank test. Conclusion: Patients with AMI might benefit from early risk stratification with the aid of 3D-STE measurements, particularly GAS and GCS-3D, but larger studies are necessary to determine the optimal cut-off values to predict MACE.

Atomic force microscopy analysis of the surface alterations of enamel, dentin, composite and ceramic materials exposed to low oral pH in GERD

Dental erosion is a significant topic in medical literature, both for gastroenterology and dental medicine. Dental structure loss has a psychosocial and functional significance. The pathogenesis of dental erosion in patients diagnosed with gastroesophageal reflux disease (GERD) characterized by the presence of an acidic oral environment after reflux episodes, is not well understood. The present study was designed to observe the effect of low oral pH in time on natural surfaces including enamel and dentine, but also on materials used in treating these dental destructions such as composites and ceramics. The acidic oral environment was estimated in relation to salivary pH. In the dental laboratory, 5-mm2 and 1-mm composite pieces of thick enamel, dentine, Emax Ceramic and Nexco Ivoclar were cut in order to be analyzed using atomic force microscopy (AFM) and to observe the surface alterations. Gastric acid was collected and mixed with saliva until a pH value of 6.0 was obtained, in which the pieces were immersed for 24, 120, 240 h. Roughness of each surface was calculated at a microstructure and nanostructure level. The results showed significant alterations in enamel and dentine exposed to a lower pH level beginning even at a short immersion time, in comparison with composites and ceramics which had no alterations. In conclusion, multidisciplinary attention should be given to detect and manage acidity of the oral cavity caused by GERD, in order to prevent dental erosion.

Major Left Bundle Branch Block and Coronary Heart Disease-Are There Any Differences between the Sexes?

Left bundle branch block is not a benign pathology, and its presence requires the identification of a pathological substrate, such as ischemic heart disease. Left bundle branch block appears to be more commonly associated with normal coronary arteries, especially in women. The objectives of our study were to describe the particularities of left bundle branch block in women compared to men with ischemic heart disease. Result: We included seventy patients with left bundle branch block and ischemic heart disease, with a mean age of 67.01 ± 8.89 years. There were no differences in the profile of risk factors, except for smoking and uric acid. The ventricular depolarization (QRS) duration was longer in men than women (136.86 ± 8.32 vs. 132.57 ± 9.19 msec; p = 0.018) and also men were observed to have larger left ventricular diameters. Left bundle branch block duration was directly associated with ventricular diameters and indirectly associated with left ventricular ejection fraction value, especially in women (R = −0.52, p = 0.0012 vs. R = −0.50, p = 0.002). In angiography, 80% of women had normal epicardial arteries compared with 65.7% of men; all these patients presented with microvascular dysfunction. Conclusion: The differences between the sexes were not so obvious in terms of the presence of risk factors; instead, there were differences in electrocardiographic, echocardiographic, and angiographic aspects. Left bundle branch block appears to be a marker of microvascular angina and systolic dysfunction, especially in women.

The role of multimodal imaging in the diagnosis of an asymptomatic patient with congenital anomaly

Anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome is a rare congenital coronary anomaly, which can cause potentially fatal complications, such as heart failure, myocardial infarction and sudden cardiac death. Only a few patients left untreated survive to adulthood. We highlight the importance of multimodal imaging in the diagnosis of ALCAPA syndrome in a young asymptomatic female patient with inducible ischemia on exercise. The patient was successfully treated with surgery.

Profile of Obesity and Comorbidities in Elderly Patients with Heart Failure

Background and Purpose

In Romania, robust data about the prevalence of obesity and heart failure are lacking, especially in the elderly; therefore, this study aims to analyze the profile of overweight and obese patients aged >65 years admitted to a Romanian hospital for worsening heart failure, and also their risk in the presence of comorbidities.

Patients and Methods

This cross-sectional study was conducted in 126 consecutive elderly patients with overweight and obesity admitted to a Romanian hospital for worsening heart failure. They were divided into three groups: with reduced (<40%) – HFrEF, mid-range (40–49%) – HFmrEF and preserved (≥50%) ejection fraction – HFpEF. Obesity was defined according to the body mass index (BMI) status: obesity, ≥30 kg/m²; overweight, 25–29.9 kg/m². The Charlson Comorbidity Index (CCI) was calculated to evaluate the severity of comorbidity, with a score ranging from 2 (only heart failure present and age >65 years) to 30 (extensive comorbidity).

Results

NT-proBNP values are negatively correlated with BMI only in patients with HFpEF. Creatinine clearance (p=0.0166), the presence of atrial fibrillation (p=0.0095) and NYHA functional class were independent predictors of increased NT-proBNP values. CCI score is negatively correlated with NT-proBNP values in patients with HFmrEF (r= −0.448, p=0.009) and HFpEF (r= −0.273, p=0.043). The CCI risk was not significantly different between the three groups.

Conclusion

Elderly heart failure patients with overweight or obesity have particular characteristics in terms of NT-proBNP values and presence of comorbidities. In the studied population, NT-proBNP levels were strongly influenced by renal function, NYHA functional class, the presence of atrial fibrillation and left ventricular ejection fraction.