Introduction: Several homeostatic changes like an increase in sympathoadrenal response and oxidative stress occur in hypoglycemia. As a result of these findings, an increase in inflammation and pre-atherogenic factors is observed and these changes may lead to endothelial dysfunction. Aim: Our study aims to reveal possible cardiac risks (systolic-diastolic functions and endothelial dysfunctions) in patients who have applied to the emergency department with hypoglycemia. Methods: This cross-sectional, case-control study included 46 hypoglycemia patients who admitted to the emergency with symptoms compatible with hypoglycemia and diagnosed with hypoglycemia and 30 healthy volunteers. All patients were evaluated with baseline echocardiography, tissue-doppler imaging(carotid and brachial artery). Also, the fasting blood tests of the patients referred to the internal medicine department were examined. Results: There were no differences between the groups regarding age, weight, body mass index, and systolic blood pressure. Total cholesterol, LDL, HDL, Vitamin B12, TSH, and fasting blood glucose levels were similar in the groups’ blood tests (all p values>0.05). We observed a statistically significant decrease in diastolic dysfunction parameters: E/A and E/e’ ratios (respectively, p=0.020 and 0.026). It was shown that insulin resistance was influential in forming these considerable differences. The patient group observed that the carotid intima-media thickness was more remarkable(p=0.001), and the brachial flow-mediated dilatation value was smaller(p=0.003), giving an idea about endothelial functions.
Introduction: The development of right atrial (RA) thrombus (RAT) is a known complication of central venous catheter insertion (CVC). Deeper insertion of CVC within the RA may increase the risk for RAT development versus those placed at the superior vena cava (SVC)-RA junction. We sought to evaluate the incidence of catheter-associated RAT as detected by transthoracic echocardiograms (TTEs), characterize thrombi though multimodal imaging, and evaluate thrombi management with follow-up imaging. Methods: A retrospective analysis was conducted of consecutive TTEs from our institution between October 1, 2018, and January 1, 2020 in which a venous catheter was visualized in the RA. Studies were reviewed in detail to determine presence of suspected RAT. Demographic data, comorbidities, laboratory values, characteristics of the catheter and the thrombus, subsequent imaging and management, and outcomes were collected. Results: A total of 364 TTEs were performed in 290 patients with a venous catheter visualized in the RA. Of these 290 patients, 15 had an imaging suspicion for RAT yielding an incidence of 5.2%. Management strategies included anticoagulation in 13 (86.7%) patients and catheter removal in 11 (73.3%) patients. At eight months follow-up, 11 (73.3%) patients had resolution of RAT based on subsequent imaging. Conclusion: In patients with deeply placed CVC catheters, the incidental detection of RAT by TTE was not trivial. Anticoagulation and catheter removal and replacement, if deemed safe, were effective methods of thrombus management. RAT as a complication of CVCs must be accounted for when addressing factors that influence depth of CVC insertion.
Mitral commissural prolapse or flail, either isolated or combined with more extensive degenerative valve disease imposes several challenges both on its diagnosis and management whilst being a risk factor for valve reoperation after mitral valve repair. Accurate identification of the prolapsing segment is often not feasible with transthoracic 2D echocardiography, with transesophageal 3D imaging then required for correct diagnosis and surgical planning. Various surgical techniques employed alone or in combination, have yielded good results in the repair of commissural prolapse. Herein, we analyze the specific characteristics of commissural disease focusing our attention on 2D and 3D echocardiographic findings and we briefly comment on techniques employed for surgical correction of the disease.
Utility of the E/e’ index in ventilated patients and those with sepsisImran Sunderji 1, Alan G Fraser 2(Reply to the letter from Filippo Sanfilippo and colleagues, ECHO-2020-0930)1 Department of Cardiology, Castle Hill Hospital, Hull, U.K.2 Department of Cardiology, University Hospital of Wales, Cardiff, U.K.Address for correspondence :Professor Alan G. Fraser,University Hospital of Wales,Heath Park,Cardiff, CF14 4XW,Wales, U.K.firstname.lastname@example.orgTelephone: +44 (0)29 2074 5366Fax: +44 (0)29 2074 4473915 wordsWe thank Sanfilippo and his colleagues for their interest in our paper, and for the opportunity thus afforded to comment on the E/e’ index in critically ill patients and in those who have severe sepsis.We agree that the E/e’ index has some utility in predicting successful weaning from mechanical ventilation, as they have shown in their most recent meta-analysis,1 but published studies show high heterogeneity, there are often only small initial differences in mean E/e’ between patients who will remain off ventilation and those who will not, and average E/e’ values in both groups are sometimes within normal or intermediate ranges. Earlier systematic reviews also concluded that a higher E/e′ ratio is associated with weaning failure in ventilated patients2 and that E/e′ (as well as other markers of diastolic dysfunction) predicts mortality in critically ill patients.3 In a large study of 161 patients, however, neither E/e’ at the lateral mitral annulus nor any other echocardiographic index predicted success in weaning.4The heterogeneity of criteria for diastolic dysfunction in these studies is illustrated by cut-points for abnormal E/e’ varying between 8 and 12 at the lateral mitral annulus and 8 and 9.6 at the medial (septal) annulus.3In ventilated as in other patients, both E and e’ are preload-dependent.5 Positive end-expiratory pressure (PEEP) reduces both; for example PEEP of 12 cm H2O decreased lateral e’ by 19.7% and E by 13.7%, so E/e’ was unchanged.6 An increase in e’ when a patient is taken off a ventilator could indicate a response to changed loading rather than an improvement in intrinsic diastolic function. Before concluding that observed changes in E/e’ imply corresponding changes in left ventricular (LV) filling pressures, we should consider if E/e’ has been validated by correlation with pulmonary capilllary wedge pressure (PCW) measured with Swan Ganz catheters, specifically in ventilated and critically ill patients.In 39 patients there was no difference in E/e’ before a trial of spontaneous breathing, between those subjects in whom it was successful (defined as PCW remaining <18 mmHg after 60 minutes; mean baseline E/e’ 8.0) and those in whom it was not (PCW increasing to >18 mmHg; baseline E/e’ 7.6).7 The area under the receiver operating characteristic curve (AUC) for E/e’ as a guide to PCW at the end of the trial of spontaneous breathing was 0.8. In an earlier study of patients in intensive care who were also breathing spontaneously, E/e’ had a modest correlation with PCW (r=0.69); a patient with E/e’ of around 10 could have a PCW ranging from <10 to >20 mmHg.8 In other studies of ventilated patients, the correlation of lateral E/e’ with PCW was 0.849 and its AUC was 0.91.10Recently, Brault et al reported that the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines for diastolic dysfunction did not accurately assess PCW in 98 ventilated and critically ill patients, of whom 54% experienced septic shock. The diagnostic score was indeterminate in 49% of patients, sensitivity and specificity were both 74%, and agreement between echocardiography and PCW was moderate (Cohen’s Kappa, 0.48). The best echocardiographic predictor of a normal PCW was not the E/e’ ratio but a lateral e′ >8.11From experimental and clinical observations it is clear that severe sepsis can depress myocardial contractile function, probably through multiple mechanisms.12 In 40 patients with sepsis, however, there were no significant correlations between serum concentrations of inflammatory cytokines and measurements of e’ or calculated E/e’.13 In another study, mortality was predicted by the APACHE II score and mitral annular systolic excursion (MAPSE) with an AUC of 0.88, while the E/e’ index was not selected as a predictor in a logistic regression analysis.14Reproducibility of echocardiographic measurements in patients with septic shock is moderate to good15 but it is difficult to rely on single observations to guide clinical decisions.In patients with sepsis and severe diastolic dysfunction, failure to respond to volume replacement may be caused by impaired early diastolic relaxation and LV suction, which cannot be detected by the E/e’ index. In a randomised trial, an intravenous infusion of esmolol to slow the heart rate prolonged LV filling and increased stroke volume, with a subsequent reduction in mortality.16 In a prospective observational study, levosimendan increased the probability of successful weaning from ventilation, and averted any increase in E/e’;17 that could also be explained by improved early diastolic relaxation and filling, since levosimendan is positively lusitropic.18 Detailed echocardiographic assessment of ventilated patients after cardiac surgery showed that levosimendan increased early diastolic strain rate by 30%.19 Thus changes in E/e’ as a marker of mean PCW do not necessarily confirm a causal relationship with any particular aspect of LV diastolic function, while more comprehensive echocardiographic analysis of pathophysiological mechanisms may be more informative.These thoughts reinforce some of the conclusions that we drew in our review. Many studies are difficult to interpret because the E/e’ index is reported without information on changes in its individual components, and because dichotomising patients into normal or diastolic dysfunction (grades) loses information from multiple continuous variables that are inter-related but may change with differing patterns according to particular circumstances. It is unwise to use discrete cut-points especially if they are unadjusted for age and gender, and mistaken to conclude that LV diastolic function has changed when there are significant differences in the E/e’ index but its mean values remain within the normal range. The optimal assessment of diastolic dysfunction in septic and ventilated patients requires a multiparametric approach and we caution against over-reliance on E/e’.
Inadvertent endocardial lead malposition is recognised as a rare incident which is usually underreported and if recognised during implantation can be easily corrected. This phenomenon is caused by the ventricular lead unintentionally crossing a pre-existing patent foremen ovale, septal defects (atrial or ventricular) or directly from the aorta via an accidental subclavian puncture resulting in the lead implanting into the left ventricle. While this is a rare occurrence we report the incidental finding of pacemaker lead malposition during a routine follow-up transthoracic echocardiogram and the benefits of three dimensional transoesophageal echocardiography in this patient prior to lead extraction.
Prosthetic valve endocarditis is a rare but serious complication of cardiac valve replacement, and echocardiography plays a fundamental role in its diagnosis and management. However, there is not much information about the use of the 3D transillumination rendering in this context. In this report we present an unusual case of prosthetic valve endocarditis that exemplifies the utility of this new tool.
Aortic atresia is uncommonly associated with atrioventricular and ventriculoarterial discordance.(1) Presence of severe regurgitation of Ebsteinoid malformation of the tricuspid valve in this subset results in reduced aortic blood flow in-utero. The hemodynamic explanation of this anomaly was reported by Celermajer and colleagues.(2) We report here a term neonate with this anomaly detect antenatally.
Background: Ibrutinib is associated with atrial fibrillation (AF), though echocardiographic predictors of AF have not been studied in this population. We sought to determine whether left atrial (LA) strain on transthoracic echocardiography could identify patients at risk for developing ibrutinib-related atrial fibrillation (IRAF). Methods: We performed a retrospective review of 66 patients who had an echocardiogram prior to ibrutinib treatment. LA strain was measured with TOMTEC Imaging Systems, obtaining peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) on 4-chamber and 2-chamber views. Statistical analysis was performed with Chi-square analysis, T-test, or binomial regression analysis, with a p-value < 0.05 considered statistically significant. Results: Twenty-two patients developed IRAF (33%). Age at initiation of ibrutinib was significantly associated with IRAF (65.1 years vs. 74.1 years, p = 0.002). Mean ibrutinib dose was lower among patients who developed IRAF (388.2 ± 121.7 vs. 448.6 ± 88.4, p = 0.025). E/e’ was significantly higher among patients who developed IRAF (11.5 vs. 9.3, p = 0.04). PALS was significantly lower in patients who developed AF (30.3% vs. 36.3%, p = 0.01). On multivariate regression analysis, age, PALS and PACS were significantly associated with IRAF. On multivariate regression analysis, only PACS remained significantly associated with IRAF while accounting for age. Conclusions: Age, ibrutinib dose, E/e’, and PALS on pre-treatment echocardiogram were significantly associated with development of IRAF. On multivariate regression analyses, age, PALS and PACS remained significantly associated with IRAF. Impaired LA mechanics add to the assessment of patients at risk for IRAF
Introduction: Coronary artery fistula (CAF) is a rare cardiac anomaly that typically presents as a continuous murmur in an otherwise asymptomatic patient. Occasionally, it can result in congestive heart failure or bacterial endocarditis. Objective: To better delineate the course of coronary artery fistula using an intracoronary injection of SonoVue contrast agent, whilst performing transthoracic echocardiography. Method and results: A referred 46-year-old male, with a history of exertional dyspnea for almost three months, was admitted to the hospital with progressive dyspnea, and assessed under suspicion of CAF. CAF was seen with a coronary angiogram, but the exact entry point in the left ventricle or left atrial wall could not be determined. CT angiography also failed to establish the drainage site , so CAG (coronary angiography) was repeated with the SonoVue contrast agent injected into LM (Left main) while using a Siemens echocardiography machine. Multiple views were obtained during the injection and revealed unusual flow in the left ventricle just below the PML (posterior mitral leaflet) and passing through the fistula to LV. Conclusion: Contrast-Enhanced Echocardiography by direct intracoronary injection of SonoVue contrast agent, is safe and can aid in the delineation of fistula drainage.
Cardiac imaging is the cornerstone of defining the etiology, quantification and management of mitral regurgitation (MR). This continues to be even more so the case with emerging trans-catheter techniques to manage MR. Transthoracic echocardiography remains the first line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative non-visual estimation, 3D volumetric data, late gadolinium, T1 and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.
Purpose: Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity. Methods: This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥ 4 mmHg. Mitral valve area by the continuity equation (MVACEQ) was used as an independent reference. The DMSI was calculated as follows: DMSI = VTILVOT / VTIMV. All-cause mortality data were collected retrospectively. Results: A total of 64 patients with DMS and 24 patients with RMS were identified. MVACEQ was larger in patients with DMS (1.43 0.4 cm2) than RMS (0.9 0.3 cm2) by ~0.5 cm2 (p = <0.001) and mean TMPG was lower in the DMS group (6.0 2 vs. 7.93 mmHg, p=0.003). A DMSI of 0.50 and ≤ 0.351 were associated with MVACEQ ≤ 1.5 and MVACEQ ≤ 1.0 cm2 (p<0.001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a non-significant trend towards worse survival in patients with MVACEQ ≤ 1.0 cm2 and DMSI ≤ 0.35, suggesting severe stenosis severity. Conclusion: Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.
A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting) a single venous cannula was placed across the interatrial septum so the distal orifice and side ports were located within the left atrium and the proximal set of side ports at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.
Background This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-Fluorodeoxyglucose–Positron Emission Tomography (FDG-PET) are limited by cost and availability. Methods We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD) between the sarcoidosis group and controls. A random effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics. Results Nine studies with 967 patients were included in our analysis. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, p< 0.001, also was significantly lower in patients who suffered Major Cardiac Events(MCE), -3.89, 95% CI -6.14, -1.64, p< 0.001 . GCS was significantly lower in the extra-cardiac sarcoidosis group as compared to controls, SMD: -3.33, 95% CI -4.71, -1.95, p< 0.001 Conclusion LVGLS and GCS were significantly lower in extra-cardiac sarcoidosis patients despite not exhibiting any cardiac symptoms. LVGLS correlates with MCEs in CS. Further studies are required to investigate the role of STE in the early screening of CS.
Vascular rings(VRs) are defined as congenital abnormalities of the aortic arch and its branches. The most common vascular rings include right aortic arch (RAA) and double aortic arches(DAA). Vascular rings can form a ring that may compress the esophagus and trachea ,which likely result feeding difficulties and respiratory distress. We have reported three cases about diagnosis of vascular rings using High-definition flow(HD-flow) render mode and spatiotemporal image correlation(STIC). In addition ,we have evaluated the postnatal imaging features of vascular rings.
Background: The change of left ventricular function deteriorated with age because of gradual increases of blood pressure may result in increased energy loss (EL) in left ventricle (LV). The present study investigated EL in LV among hypertensive elderly patients and examined factors contributing to EL. Methods: A single-center retrospective study was performed on elderly hypertensive outpatients (65 years) who underwent echocardiography (N=105). EL in the LV was measured using an vector flow mapping system, and factors affecting peak EL during the early diastolic phase (ED-EL), late diastolic phase (LD-EL), and systolic phase (Sys-EL) were evaluated. Result: Mean age was 79.9±6.4 years (male 43%). Mean ED-EL, LD-EL, and Sys-EL were 42.1±46.7, 75.6±60.2, and 40.4±40.2 mJ/N/s. In a stepwise regression analysis, the E wave peak velocity of transmitral flow (unstandardized B=0.002, 95%CI 0.001 to 0.002, standardized β=0.547, p<0.001) and stroke volume in the LV outflow tract (LVOT) (B=0.001, 95%CI 0.000 to 0.001, β=0.190, p=0.034) were identified as factors affecting ED-EL. The factors affecting LD-EL were the E/A ratio (B=-0.122, 95%CI -0.180 to -0.064, β=-0.451, p<0.001) and peak velocity in LVOT (unstandardized B=0.001, 95%CI 0.0001 to 0.001, β=0.339, p=0.003). The factors influencing Sys-EL were peak velocity in LVOT (B=0.001, 95%CI 0.001 to 0.001, β=0.619, p<0.001) and the E/A ratio (B=-0.050, 95%CI -0.087 to -0.013, β=-0.241, p=0.008). Conclusion: Peak EL in the LV was higher during diastolic phase than systolic phase among elderly hypertensive patients. Peak EL during each phase was affected by systolic blood flow in LVOT and LV transmitral flow.
Bioprosthetic valve thrombosis (BPVT) is more common than previously thought and likely underreported. BPVT can be accurately diagnosed with cardiac imaging and treated successfully with anticoagulation, thus preventing re-operation. We hereby report a case of recurrent BPVT in the mitral position successfully treated with anticoagulation along with review of literature.
Introduction In the current literature, several studies show that pulmonary artery stiffness (PAS) is associated with right ventricular (RV) dysfunction, pulmonary arterial hypertension (PAH), and disease severity in patients with structural heart disease, human immunodeficiency virus (HIV), and chronic lung disease. Hence, in this study, we aimed to use PAS to show the early changes in the pulmonary vascular bed in patients with cirrhosis. Material and Methods In this prospective, cross-sectional study, 39 subjects who were being followed up with cirrhosis and 41 age- and sex-matched healthy participants were enrolled. For each case, the PAS value was calculated by dividing mean peak velocity of the pulmonary flow by the pulmonary flow acceleration time (PfAT). Results The measured PAS was 23.62 ± 5.87 (Hz/msn) in cirrhotic patients and 19.09 ± 4.16 (Hz/msn) in healthy subjects (p < 0.001). We found a positive statistical significance between PAS and systolic pulmonary arterial pressure (sPAP) (r = 0.378; p = 0.001). PAS was an independent predictor that was associated with cirrhosis disease according to multivariate logistic regression analysis (OR: 1.209; 95% CI: 1.059–1.381; p = 0.005). Conclusion Based on the study results, we consider that PAS may help in the early detection of changes in the pulmonary vascular bed, even if the RV function parameters or sPAP are within the normal range.