A document by Tasneem Naqvi. Click on the document to view its contents.

Aim. To investigate abnormalities in myocardial strain and classic echocardiographic indices and coronary flow reserve (CFR), in younger vs older CKD patients. Methods. Sixty consecutive CKD patients (<60 years old n=30, ≥60 years old n=30) and 30 healthy controls (age- and gender-matched with younger CKD patients) were recruited. An echocardiographic assessment including myocardial strain indices was performed at baseline and following dipyridamole administration in all participants. Results. Younger CKD patients had higher E/e’, left ventricular mass index and relative wall thickness and lower E’ (p<0.005 for all) compared to healthy controls. Older CKD patients had lower E/A and E’ (p<0.05 for both) compared to younger CKD patients; these differences did not remain significant after adjustment for age. CFR was higher in healthy controls compared to younger and older CKD patients (p<0.05 for both) without a significant difference between CKD groups. Dipyridamole-induced changes did not differ significantly among the 3 groups. Conclusions. Compared to healthy controls, impaired coronary microcirculation and left ventricular diastolic function, but not myocardial strain abnormalities, are found in young CKD patients and deteriorate with aging.

Objectives: Data on intraoperative three-dimensional derived right ventricular free-wall strain (3D-RV FWS) is sparse. We sought to evaluate the normal range of intraoperative 3D-RV FWS in patients scheduled for coronary artery bypass graft (CABG) surgery and compare to conventional echocardiographic parameters. Design: Prospective observational study. Setting: Single university hospital. Participants: 150 patients with preserved left and right ventricular function and sinus rhythm, without significant heart valve disease or pulmonary hypertension undergoing isolated onpump CABG surgery, with an uneventful, complication-free intraoperative course. Interventions: 3D-RV FWS analysis and conventional echocardiographic assessment of right ventricular function were performed intraoperatively in anesthetized and ventilated patients using transesophageal echocardiography (TEE). All echocardiographic measurements were performed under stable hemodynamic conditions and predefined fluid management without any vasoactive support or pacing. Measurements and Main Results: We used TomTec 4D RV-Function 2.0 software for assessment of 3D-RV FWS and three-dimensional right ventricular ejection fraction (3D-RV EF). Philips QLAB 10.8 was used to evaluate tissue velocity of the tricuspid annulus (RV S´), tricuspid annular systolic excursion (TAPSE), and RV fractional area change (FAC). Assessment of 3D-RV FWS was feasible in 95% of patients. No included patient experienced a serious perioperative complication. In our group of patients, median values with interquartile range (IQR) for 3D-RV FWS and 3D-RV EF were - 25.2 (IQR -29.9 - -21.8) and 46.3% (IQR 41.0 - 50.1%), respectively. RV FAC, RV S´ and TAPSE accounted for 39.7% (IQR 34.5 - 44.4%), 14.8cm/s (IQR 11.8 - 19.0cm/s) and 22 mm (IQR 20-25mm). Normal range (2.5% to 97.5% percentile) for 3D-RV FWS was -37.1 to -12.8. There was no relevant correlation of 3D-RV FWS to postoperative outcome in this group of CABG patients. Conclusion: We present distribution values for intraoperative 3D-RV FWS and conventional parameters of RV function assessment in a healthy on-pump CABG patient population without serious perioperative complications. We observed no correlations of these parameters with any of the outcome parameters considered. Therefore, we consider these values to be intraoperative TEE-assessed normal values that can be expected in onpump CABG patients.

Background Left ventricular (LV) systolic and diastolic functions are important cardiovascular risk predictors in patients with hypertension. However, data on segmental, layer-specific strain, and diastolic strain rates in these patients are limited. The aim of this study was to investigate segmental two-dimensional strain rate imaging (SRI)-derived parameters to characterize LV systolic and diastolic function in hypertensive individuals compared with that in normotensive individuals. Methods The study sample comprised 1194 participants from population studies in Arkhangelsk and Novosibirsk, Russia, and 1013 individuals from the Seventh Tromsø Study in Norway. The study population was divided into four subgroups: A. healthy individuals with normal blood pressure (BP), B. individuals on antihypertensive medication with normal BP, C. individuals with systolic BP 140–159 mmHg and/or diastolic BP >90 mm HG, and D. individuals with systolic BP ≥160 mmHg. In addition to conventional echocardiographic parameters, global and segmental layer-specific strains and strain rates in early diastole and atrial contraction (SR E, SR A) were extracted. The strain and SR (S/SR) analysis included only segments without strain curve artifacts. Results With increasing BP, the systolic and diastolic global and segmental S/SR gradually decreased. SR E, a marker of impaired relaxation, showed the most distinctive differences between the groups. In normotensive controls and the three hypertension groups, all segmental parameters displayed apico-basal gradients, with the lowest S/SR in the basal septal and highest in apical segments. Only SR A did not differ between the segmental groups but increased gradually with increasing BP. End-systolic strain showed incremental epi-towards endocardial gradients, irrespective of the study group. Conclusion Arterial hypertension reduces global and segmental systolic and diastolic left ventricular S/SR parameters. Impaired relaxation determined by SR E is the dominant factor of diastolic dysfunction, whereas end-diastolic compliance (by SR A) does not seem to be influenced by different degrees of hypertension. Segmental strain, SR E and SR A provide new insights into the LV cardiomechanics in hypertensive hearts.

A giant ascending aortic aneurysm associated with a ruptured sinus of Valsalva is rare. A 53-year-old male patient successfully underwent Bentall procedure after multimodality imaging which enable the correct diagnosis to be established and intraoperative transesophageal echocardiography provides additional information on the surgical planning.

Background: Left atrial appendage occlusion (LAAO) in the treatment of atrial fibrillation (AF) has become a hot topic in clinical research in recent years. Case presentation: we report a 68-year-old female patient who was admitted for “recurrent palpitations for three years,” with an electrocardiogram finding of atrial fibrillation (Figure [1](#fig-cap-0001)). The diagnosis upon admission was: (1) arrhythmia: paroxysmal AF (CHA2DS2-VASc: 4 points, HAS-BLED: 3 points), (2) Grade 3 hypertension, and (3) carotid plaque with internal carotid artery stenosis. The patient had a history of AF for three years with poor drug treatment effect. The patient was unable to tolerate anticoagulation therapy. We gave the patient a one-stop procedure treatment of “AF radiofrequency ablation + LAAO” under the guidance of 3D printing technology. There was no recurrence of AF or paravalvular leakage at the three-month and one-year follow-ups. Conclusions: The 3D printing technology guide the one-stop operation of “AF radiofrequency ablation + LAAO” is helpful. But it whether can improve the prognosis and quality of life of patients, further multi-center research and large data statistics are required.

Background: In low-income nations, Rheumatic valvular heart disease remains a major cause of morbidity and premature deaths. Accurate prevalence data in Egypt are still lacking yet highly desirable to facilitate health care planning. Methodology: An cluster sample of school children in eastern Egyptian Governorates was examined clinically and echocardiographically (using abbreviated protocol) for detection of rheumatic valvular heart disease based on 2012 World Heart Federation criteria (the Doppler and the morphological criteria) for diagnosis. According to echocardiography interpretation, participants were categorized as having definite RHD, borderline RHD or no RHD. Results: A total A total of 1680 students aged between 6 and 18 years were screened, 119 echocardiographic studies were non-interpretable; so, a total of 1560 studies were evaluated. From the total screened students, 1560 studies were adequate and interpretable according to the criteria specified in the methods section. This revealed a prevalence of 2.3% of the sample with RHD without adding the equivocal cases. The most prevalent lesion as detected by echocardiography was mitral regurgitation (29% of definite RHD cases). Conclusion: Rheumatic valvular heart disease remains prevalent in Egypt and the findings of this study should influence early detection, primary and secondary prevention, and adequate future national health plans.

Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve or, less frequently, the left ventricular outflow tract. We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.

We present a case of a 13-day-old neonate with shock who was diagnosed with persistent fifth aortic with critical coarctation by cardiac point-of-care ultrasound and surgery confirmed the anomalies. This case demonstrates the value of cardiac point-of-care ultrasound in detecting congenital anomalies of great vessels in neonates and may be beneficial in clinical management.

Background: Literature suggests that left ventricular global longitudinal strain (LV-GLS) on speckle echocardiography has the potential to predict cardiotoxicity amongst breast cancer patients receiving chemotherapy such as anthracycline, taxane, cyclophosphamide, and trastuzumab. Our study aimed to collect evidence for the prognostic value of LV-GLS for predicting chemotherapy-induced cardiotoxicity in breast cancer patients. Methods: A detailed search of the PubMed, Google Scholar, Cochrane Library, and Scopus databases was conducted for published articles up to August 31, 2022. In our meta-analysis, we looked at 13 studies with a total of 1007 breast cancer patients getting chemotherapy that looked at the predictive value of GLS. Results: Absolute GLS change during treatment showed a pooled sensitivity of 84% (95% CI: 74% to 91%) and a pooled specificity of 77% (95% CI: 68% to 84%).  For a relative change in GLS, we observed a pooled sensitivity of 76% (95% CI: 56% to 89%) and a pooled specificity of 83% (95% CI: 73% to 90%).  For an absolute change in GLS, we observed a positive likelihood ratio (LR), and the negative LR was 4 and 0.21.  SROC with prediction and confidence intervals represents a promising summary area under the curve (sAUC) of 0.88, 95% CI ranges from 0.85 to 0.91 for absolute change in GLS, as well as for relative change (sAUC, 0.87, 95% CI 0.84 to 0.90). Conclusion: Our results demonstrated an estimation of LV-GLS after the beginning of required chemotherapy, including anthracyclines and trastuzumab, had a promising prognostic value for predicting the likelihood of CTRCD. To confirm our findings, well-designed prospective adequately powered diagnostic randomised trials are necessary.

Accessory tricuspid valve (ATV) is a rare congenital anomaly that is often seen in complex congenital anomalies in children with very few reported cases in adults. We report a case of isolated ATV in an asymptomatic adult with no other congenital defects along with illustrative transesophageal echocardiographic 2D, 3D, high-resolution photo-realistic images.

We present a case of a 60 year old male who found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 hours and he was referred for TEE guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however the appendage was large and had a tongue like accessory lobe along with spontanous contrast on the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.

Introduction. The concept of ventricular anatomy as a single muscular band was initially described by Francisco Torrent-Guasp in 1972 1 and since then, there have been multiple novel contributions to the understanding of the morphology and function of the heart. To date, this concept has been supported and denied by multiple groups of professionals reflecting both the enthusiasm and resistance to the new concept of the single muscle band model. Currently, the single muscular band is the model that meets all the requirements to explain the performance of cardiac mechanics, and its distinctive feature to determine the characteristics of the structure.

A previously healthy 9-year-old girl was referred to us for the evaluation of a murmur on routine clinical examination. Routine electrocardiogram and chest X-ray were normal. The cardiac enzymes were normal. Combining ultrasound and CCTA, it was confirmed that the hemodynamics of the heart was a left-to-right shunt and that RVOT stole blood from the left ventricle through the single coronary artery (SCA).

A previously healthy 68-year-old woman presented to the outpatient clinic with a 2-month history of palpitation. Physical examination and laboratory findings were unremarkable. Her electrocardiogram showed sinus tachycardia with a heart rate of 115 beats/m. Transthoracic echocardiography (TTE) showed a normal ejection fraction with a huge mass in the left atrium (Figure 1a). Transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (MRI) were performed for further evaluation. TEE revealed a hyperechogenic, well-demarcated mass in the left atrium, that was attached to the interatrial septum and adjacent to the left pulmonary veins (Figure 1b, 1c,1d). Cardiac MRI revealed a heterogeneous left atrial mass located on the fossa ovalis, 58x52x54 mm in size and markedly hyperintense on a STIR sequence (Figure 1e). These findings were suggestive of a benign cardiac tumour such as myxoma or hemangioma. A decision for surgery was made and coronary angiography was performed which showed that the branch of the circumflex artery supplied and surrounded the mass in the form of a net (Figure 1e). The patient underwent complete excision of the mass (Figure 2a, 2b). Histopathological examination revealed a nested architecture of epitelioid cells, the nests are round or oval in shape and invested by an fibrovascular stroma. Tumor cells had centrally and eccentrically located round nuclei and cytoplasm ranging from finely granular to eosiniphilic. At immunohistochemical staining, the nests were positive for chromogranin A, negative for cytokeratin (Figure 2c, 2d, 2e, 2f). A diagnosis of paraganglioma was made. After an uneventful postoperative course, she was discharged home on postoperative day 6. Cardiac paraganglioma is a very rare neuroendocrine tumour and accounts for less than 1% of primary cardiac tumours (1,2). Approximately 10% of paragangliomas may be malignant, complete surgical resection remains the first-line treatment (3).

Objective: Peripartum cardiomyopathy (PPCM) diagnosis made by excluding identifiable causes of heart failure (HF) and occurs end of the pregnancy or during the postpartum period of five months. It presents a clinical HF spectrum with left ventricular systolic dysfunction. Background: The purpose of this study is to retrospectively evaluate the clinical characteristics, cardiac magnetic resonance (CMR) imaging features, and end-points consisting of left ventricle recovery, left ventricular assist device implantation, heart transplantation, and all-cause mortality. Method: Outpatient HF records between 2008 to 2021 were screened. Thirty-seven patients were defined as PPCM. Twenty-five patients had CMR evaluation at the time of diagnosis, and six patients were re-evaluated with CMR. Results: The mean age was 30.5±5.6 years, and the mean LVEF was 28.2±6.7%. In thirteen(35.7%) patients, LVEF recovered during the follow-up course. The median recovery time was 281(IQR [78-358]) days. LVEF on CMR was 35.3±10.5, and three patients exhibited late gadolinium enhancement(LGE) patterns. Sub-endocardial and mid-wall uptake pattern types were detected. 18(75%) patients met the Petersen left ventricle non-compaction cardiomyopathy(LVNC) criteria. Patients with NC/C ratio lower than 2.3 had lower LVEDVi and LVESVi (124.9±35.4,86.4±7.5, p=0.003;86.8±34.6,52.6±7.6, p=0.006), respectively. The median follow-up time was 2129 (IQR [911-2634]) days. The primary endpoint-free one-year survival was 88.9%(event rate 11.1%), and five-year survival was 75.7%(event rate 24.3%). Conclusion: In a retrospective cohort of PPCM patients, 35.7% of patients’ LVEF recovered, and the primary end-point of free-five-year survival was 75%. Twenty-five patients were assessed with CMR; three of four met the Petersen CMR-derived LVNC at initial evaluation.

Abernethy malformation, also known as congenital extrahepatic shunt, is a rare anomaly characterized by partial or complete diversion of the portal blood into the systemic venous circulation. The clinical manifestations of Abernethy malformation during childhood include neonatal cholestasis, failure to thrive, mental retardation, and other congenital defects. We report a case of Abernethy malformation Type Ⅱ in a 9-year-old boy whose left ventricle was slightly enlarged because of several major aortopulmonary collateral arteries but normal laboratory examinations five years earlier. The characteristics of congenital heart disease in patients with Abernethy malformation are discussed. We propose that enlargement of the left ventricular with systemic-pulmonary collateral circulation should raise the suspicion of Abernethy malformation.

Background: As transcatheter aortic valve replacement (TAVR) procedures become more widely available, there is a growing need to monitor and evaluate postoperative outcomes accurately. The energy loss index (ELI) of the ascending aorta has been commonly used to examine the agreement between the echocardiographic and Gorlin measurement of the aortic valve area. Objectives: This project aims to demonstrate a link between ELI values and mortality following implanted TAVR valves and determine an ELI cutoff value associated with post-TAVR events. Method: We retrospectively reviewed patients undergoing TAVR from 2012 – 2017. We calculated ELI values for patients immediately postoperative after a TAVR procedure. Using Receiver-Operator Characteristic and Cox Regression analyses, we identified a cutoff value to distinguish between high and low-risk patients. Results: This study showed ELI ≤ 1.34 (hazard ratio, 1.783; 95% confidence interval 1.231-2.583, p=0.002) as representative of patients with a high risk of mortality post-TAVR. Additionally, post-TAVR, ejection fraction increased by 3.5 percent (p<0.001), and the aortic valve effective orifice area increased by 1.25 cm squared (p<0.001) while the mean transvalvular gradient decreased by 33.6 mmHg (p<0.001) and the peak transvalvular gradient decreased by 49.7 mmHg (p<0.001). Conclusion: ELI is an additional prognostic factor that should be considered during risk assessment before TAVR. This study shows that patients with ELI ≤ 1.34 had decreased cumulative survival post-TAVR. These patients had a fivefold increased risk of death following TAVR.