Aortic Regurgitation Jet Research Articles

Abstract 14599: A Pilot Rheumatic Heart Disease Screening Program Using Portable, Handheld Echocardiography in Rivas, Nicaragua

Introduction: Portable, handheld echocardiography offers several advantages for rheumatic heart disease (RHD) screening in low-resource settings. Analyses of focused protocols using handheld echocardiography have yielded acceptable sensitivity and specificity for diagnosis of RHD, including in those performed by non-expert sonographers. Previous studies estimate high burden of RHD in Nicaragua. We conducted a pilot community-based RHD screening program using handheld echocardiography in Rivas, Nicaragua using contemporary RHD diagnostic criteria. Methods: Non-expert sonographers were trained using the GE Vscan Extend TM device and a simplified version of the 2012 World Heart Federation criteria for diagnosis of RHD. Referral criteria for complete echocardiogram included the presence of a mitral regurgitant jet of > 2.0 cm, aortic regurgitant jet > 1.0 cm, or any morphologic abnormality of the mitral or aortic valve, as well as left ventricular dysfunction or significant congenital heart disease. Participants were recruited by convenience-based sampling in communities throughout Rivas, Nicaragua. Participants were notified at the point-of-care of need for complete echocardiogram. All studies were overread asynchronously by expert readers for diagnostic accuracy. Results: Between March 2022 and April 2023, 494 screening echocardiographic studies were performed and evaluated for diagnostic accuracy. The median age was 36.3 years (IQR 19.2, 56.2), 22% of participants were <18 years of age, and 60% of participants were female. There were 17.6% of participants referred for complete echocardiogram at the point-of-care compared with 13.0% meeting referral criteria on expert review. Negative and positive predictive values for non-expert vs. expert assessment were 92.4% and 62.1%, respectively. Cohen’s kappa for inter-rater reliability was 0.338, suggesting fair agreement. Conclusions: This pilot program demonstrated the feasibility of a screening program for RHD in rural Nicaragua with non-expert sonographers. Lessons from this program are intended to inform future epidemiological studies to determine the population prevalence and longitudinal outcomes of RHD in this region.

Fluid Mechanical Effects of Fetal Aortic Valvuloplasty for Cases of Critical Aortic Stenosis with Evolving Hypoplastic Left Heart Syndrome

Fetuses with critical aortic stenosis (FAS) are at high risk of progression to HLHS by the time of birth (and are thus termed “evolving HLHS”). An in-utero catheter-based intervention, fetal aortic valvuloplasty (FAV), has shown promise as an intervention strategy to circumvent the progression, but its impact on the heart’s biomechanics is not well understood. We performed patient-specific computational fluid dynamic (CFD) simulations based on 4D fetal echocardiography to assess the changes in the fluid mechanical environment in the FAS left ventricle (LV) directly before and 2 days after FAV. Echocardiograms of five FAS cases with technically successful FAV were retrospectively analysed. FAS compromised LV stroke volume and ejection fraction, but FAV rescued it significantly. Calculations to match simulations to clinical measurements showed that FAV approximately doubled aortic valve orifice area, but it remained much smaller than in healthy hearts. Diseased LVs had mildly stenotic mitral valves, which generated fast and narrow diastolic mitral inflow jet and vortex rings that remained unresolved directly after FAV. FAV further caused aortic valve damage and high-velocity regurgitation. The high-velocity aortic regurgitation jet and vortex ring caused a chaotic flow field upon impinging the apex, which drastically exacerbated the already high energy losses and poor flow energy efficiency of FAS LVs. Two days after the procedure, FAV did not alter wall shear stress (WSS) spatial patterns of diseased LV but elevated WSS magnitudes, and the poor blood turnover in pre-FAV LVs did not significantly improve directly after FAV. FAV improved FAS LV’s flow function, but it also led to highly chaotic flow patterns and excessively high energy losses due to the introduction of aortic regurgitation directly after the intervention. Further studies analysing the effects several weeks after FAV are needed to understand the effects of such biomechanics on morphological development.

A Case of Mechanical Hemolytic Anemia due to Aortic Regurgitation Jet Collision with the Mitral Valve Stent-Post

A Case of Mechanical Hemolytic Anemia due to Aortic Regurgitation Jet Collision with the Mitral Valve Stent-Post

Intraoperative transesophageal echocardiography reveals diastolic mitral regurgitation caused by an aortic regurgitation jet.

Intraoperative transesophageal echocardiography reveals diastolic mitral regurgitation caused by an aortic regurgitation jet.

P108 PLEURAL EFFUSION AND THE POSTERIOR THORACIC WINDOW: ONE MORE CHANCE TO IMAGE THE AORTIC VALVE

Abstract A 85–year–old woman was admitted to our institution with acute respiratory distress. Clinical examination revealed a 5/6 systo–diastolic murmur radiating to both carotid arteries and bilateral lung crackles. Laboratory workup was notable for a N–terminal pro–brain natriuretic peptide (NT–proBNP) of 15.000 ng/L (normal range: < 300 ng/L) and a moderate high–sensitive troponin T elevation of 245 ng/L (normal range: < 14 ng/L) with no increase on serial testing. The hemoglobin and renal function was normal. Evaluation by chest X–ray showed bilateral diffuse pulmonary infiltrates consistent with pulmonary edema and bilateral pleural effusion. The patient was admitted in CCU. A transthoracic echocardiogram was performed bedside, but it was extremely difficult to obtain good quality images from standard view given the ortopnoic decubitus of the patient. However, the aortic valve was heavily calcified and severe aortic stenosis was documented with a mean gradient of 42 mmHg from apical 5 chambers view; 35 mmHg from right parasternal view, with an functional aortic valve area ≈0.6 cm2 (figure, upper panel). Left ventricle shows eccentric hypertrophy and a moderate diffuse reduction of ejection fraction (EF 35–40%). Then, the patient was positioned sitting upright, because the left pleural effusion offered an additional acoustic window—the posterior thoracic window (PTW)—that allowed better alignment of the ultrasound beam with the aortic jet. Mean gradient was recorded definitely higher than from standard view at 50 mm Hg. Moreover, aortic regurgitation that appeared mild from standard view was documented as significant from PTW. In fact, a proper alignment of the aortic regurgitation jet was feasible from this view with a quantification of severity with multiparameter criteria as suggested from the guidelines (PHT 166 ms, Vena contracta 8 mm; Rvol 60 ml). (Figure, lower panel) Conclusion Obtaining adequate echocardiographic images in critically ill patients is important for better diagnosis and treatment. For several reasons, this group of patients remains among the most challenging with regard to quality of echocardiographic images. In presence of pleural effusion and technically difficult echo exams, the PTW should be considered in the assessment of cardiac structures including aortic valve as a potentially useful option to provide further diagnostic information.

Automated Analysis of Doppler Echocardiographic Videos as a Screening Tool for Valvular Heart Diseases

ObjectivesThis study sought to develop a deep learning (DL) framework to automatically analyze echocardiographic videos for the presence of valvular heart diseases (VHDs). BackgroundAlthough advances in DL have been applied to the interpretation of echocardiograms, such techniques have not been reported for interpretation of color Doppler videos for diagnosing VHDs. MethodsThe authors developed a 3-stage DL framework for automatic screening of echocardiographic videos for mitral stenosis (MS), mitral regurgitation (MR), aortic stenosis (AS), and aortic regurgitation (AR) that classifies echocardiographic views, detects the presence of VHDs, and, when present, quantifies key metrics related to VHD severities. The algorithm was trained (n = 1,335), validated (n = 311), and tested (n = 434) using retrospectively selected studies from 5 hospitals. A prospectively collected set of 1,374 consecutive echocardiograms served as a real-world test data set. ResultsDisease classification accuracy was high, with areas under the curve of 0.99 (95% CI: 0.97-0.99) for MS; 0.88 (95% CI: 0.86-0.90) for MR; 0.97 (95% CI: 0.95-0.99) for AS; and 0.90 (95% CI: 0.88-0.92) for AR in the prospective test data set. The limits of agreement (LOA) between the DL algorithm and physician estimates of metrics of valve lesion severities compared to the LOAs between 2 experienced physicians spanned from −0.60 to 0.77 cm2 vs −0.48 to 0.44 cm2 for MV area; from −0.27 to 0.25 vs −0.23 to 0.08 for MR jet area/left atrial area; from −0.86 to 0.52 m/s vs −0.48 to 0.54 m/s for peak aortic valve blood flow velocity (Vmax); from −10.6 to 9.5 mm Hg vs −10.2 to 4.9 mm Hg for average peak aortic valve gradient; and from −0.39 to 0.32 vs −0.31 to 0.32 for AR jet width/left ventricular outflow tract diameter. ConclusionsThe proposed deep learning algorithm has the potential to automate and increase efficiency of the clinical workflow for screening echocardiographic images for the presence of VHDs and for quantifying metrics of disease severity.

Valvular changes after aortic valve neo-cuspidization in children: A case series.

Aortic valve neo-cuspidization (AVNeo), a procedure wherein the aortic valve is reconstructed utilizing an autologous pericardium, has recently been more commonly performed in children. However, the postoperative morphological changes in the aortic valve of pediatric patients remain unknown. The current study aimed to describe the intraoperative and postoperative findings of aortic regurgitation (AR) and stenosis (AS) after AVNeo in children. This case series describes the morphological changes in AR and AS, and their severity, between the perioperative period and 3 months postoperative period after AVNeo in children (<18 years) who underwent AVNeo between April 2016 and March 2020. Data were collected at two measurement points: (i) intraoperative transesophageal echocardiography after weaning from cardiopulmonary bypass (io-TEE); (ii) postoperative transthoracic echocardiography 3 months after the procedure (po-TTE). Seven patients were included in this case series. The number of postoperative AR sites and the ratio of AR jet area to the left ventricular outflow tract area showed a tendency to decrease between io-TEE and po-TTE. All AR sites were integrated during the postoperative period. One patient identified developed intraoperative AS, which maintained its severity after AVNeo. Most cases exhibited spontaneous improvement in AR, while one developed postoperative AS. Further prospective investigation is, therefore, needed to explore surgical outcomes following AVNeo among children.

Diagnostic value of vena contracta area measurement using three‐dimensional transesophageal echocardiography in assessing the severity of aortic regurgitation

Purpose Transthoracic echocardiography (TTE) provides noninvasively quantitative assessment of aortic regurgitation (AR) severity, but its diagnostic accuracy depends on image quality. Two-dimensional transesophageal echocardiography (TEE) is a semi-invasive procedure that is excellent in evaluating AR mechanism. However, quantitative assessment may be challenging due to restrictions in probe manipulation. This study aimed to investigate the diagnostic value of three-dimensional TEE to measure the vena contracta area (3DVCA) of AR. Methods The subjects comprised 62 patients (age, 65 ± 16 years) whose AR was evaluated using TEE. The 3DVCA and semi-quantitative TEE parameters, such as the ratio of AR jet width to left ventricular outflow tract (jet/LVOT) and the vena contracta width (VCW) of AR jet, were compared using angiography grade and quantitative TTE measurements including regurgitant volume (RVol) and effective regurgitant orifice area (EROA). The diagnostic accuracy was determined using receiver operating characteristic (ROC) analysis, and the reproducibility of 3DVCA was also evaluated. Results In 3DVCA, less overlap between angiography grades were observed. Correlation with RVol or EROA was better in 3DVCA than in Jet/LVOT or VCW. The area under the ROC curve was .737 for jet/LVOT, .773 for VCW, and .849 for 3DVCA, respectively. The optimal cutoff value of 3DVCA was ≥.31 cm2 for grading severe AR. Inter- and intra-observer reproducibility of 3DVCA were .92 and .97, respectively. Conclusions The 3DVCA method using TEE showed high diagnostic accuracy and reproducibility. 3DVCA deserves use in accurately assessing AR severity, especially in patients who present difficulty in quantitative Doppler assessment using TTE.

Pulsation of catheter during coronary angiography: Is it a sign of severe aortic regurgitation?

A 48-year-old male patient was admitted to our outpatient clinic with complaints of shortness of breath. He also had a holo-diastolic murmur at the right sternal border and an apical impulse being displaced laterally and inferiorly. Transthoracic echocardiography showed a severe aortic regurgitation without aortic valve stenosis and a mildly dilated left ventricle accompanied by an ejection fraction of 55%. The aortic regurgitation jet was eccentric and there were significant holodiastolic flow reversals in the descending thoracic aorta. Surgical management was advised for this patient because of symptomatic severe aortic regurgitation. Then, the patient underwent preoperative coronary angiography through the right femoral artery route. The left coronary ostium could be engaged with a 6 Fr Judkins left diagnostic catheter; however, the catheter jumped through the ascending aorta. Afterwards, the catheter was engaged and again jumped through the ascending aorta. Engagement and jumping cycles observed between successive systole to diastole. In our opinion, this catheter movement is explained by wide pulse pressure, like the severe characteristic physical findings of severe aortic regurgitation. Further studies are needed to understand whether this catheter movement is angiographically evidence of severe aortic regurgitation.

Eccentric aortic regurgitation jet: Is it benign or needs attention?

Eccentric aortic regurgitation jet: Is it benign or needs attention?

Comprehensive assessment of the aortic valve in critically ill patients for the non-cardiologist. Part II: Chronic aortic regurgitation of the native valve.

Inadequate diastolic closure of the aortic valve causes aortic regurgitation (AR). Diastolic regurgitation towards the left ventricle (LV) causes LV volume overload, resulting in eccentric LV remodelling. Transthoracic echocardiography (TTE) is the first line examination in the work-up of AR. TTE allows quantification of left ventricular end-diastolic diameter and volume and left ventricular ejection fraction, which are key elements in the clinical decision making regarding the timing of valve surgery. The qualitative echocardiographic features contributing to the AR severity grading are discussed: fluttering of the anterior mitral valve leaflet, density and shape of the continuous wave Doppler signal of the AR jet, colour flow imaging of the AR jet width, and holodiastolic flow reversal in the descending thoracic aorta and abdominal aorta. Volumetric assessment of the AR is performed by measuring the velocity time integral of the left ventricular outflow tract (LVOT) and transmitral valve (MV) plane, and diameters of LVOT and MV. We explain how the regurgitant fraction and effective regurgitant orifice area (EROA) can be calculated. Alternatively, the proximal isovelocity surface area can be used to determine the EROA. We overview the utility of pressure half time and vena contracta width to assess AR severity. Further, we discuss the role of transoesophageal echocardiography, echocardiography speckle tracking strain imaging, cardiac magnetic resonance imaging and computed tomography of the thoracic aorta in the work-up of AR. Finally, we overview the criteria for valve surgery in AR.

Clinical implications of exercise-induced regional wall motion abnormalities in significant aortic regurgitation.

Significant aortic regurgitation (AR) is sometimes accompanied by regional wall motion abnormalities (RWMA) during exercise stress echocardiography. The aim of this study was to estimate the association between RWMA after exercise and in the presence of significant AR in patients with coronary artery disease (CAD) or volume overload and to predict the eventual need for aortic valve replacement (AVR). We retrospectively reviewed 182 patients with significant AR who underwent exercise echocardiography. In addition, we investigated patients with AR who underwent coronary angiography (CAG) or coronary computed tomography angiography (CCTA) and were diagnosed with CAD. The presence of RWMA after exercise was defined as newly developed RWMA after exercise and included all changes in wall motion. Patients were divided into two groups according to the presence of RWMA after exercise: the RWMA group (n=42) and non-RWMA group (n=140). In the RWMA group, 31 patients (73.8%) underwent coronary artery evaluation by CAG or CCTA. Only two patients in the RWMA group were diagnosed with current CAD and underwent percutaneous coronary intervention. Patients with RWMA were older (61.6±10.8 vs 52.0±13.7years, P<.001), had more severe AR (54.8% vs 32.9%), and underwent AVR more frequently (40.5% vs 14.3%, P=.001) than patients without RWMA. METs (odds ratio [OR], 0.796; P=.019), difference between rest and postexercise left ventricular end-diastolic volume (OR, 0.967; P=.001), and the difference between pre- and postexercise left ventricular end-systolic volume (OR, 1.113; P<.001) were identified as independent factors associated with RWMA after exercise according to multivariable logistic regression analysis. The majority of wall motion changes were seen in the lateral and inferior segments, and the locations of wall motion changes were relatively consistent with the direction of the AR jet. The relationship between RWMA after exercise and time to AVR was investigated by simple linear regression (hazard ratio [HR], 3.402; P<.001). After adjusting for baseline parameters of diastolic blood pressure, left ventricular end-systolic dimension (LVESD), aorta size, deceleration time, and METs, the presence of RWMA after exercise was not predictive of time to AVR (HR, 1.106; P=.81). On the other hand, without forcible entry of RWMA after exercise, LVESD (HR, 1.119; P<.001) and METs (HR, 0.828; P=.006) independently predicted the eventual need for AVR as an outcome. The degree of change in wall motion from rest to exercise in those with significant AR was not correlated with CAD, but was correlated with the severity of volume overload and exercise-induced preload changes, as well as the direction of the AR jet. In addition, RWMA after exercise had no role in predicting the need for AVR.

New Model for Non-Invasive Echocardiographic Assessment of Pulmonary-Capillary Wedge Pressure in Patients With Aortic and Mitral Regurgitation

The pulmonary-capillary wedge pressure (PCWP) is a central parameter of cardiac function. In this work, we propose an equation based on a simple physical model, which should be applicable to any class of patient, provided they present some level of aortic and mitral regurgitation. We modeled the left cardio-circulatory system as three chambers placed in a series as follows: left atrium (LA), left ventricle (LV), and aorta (A). Starting from the principle of energy conservation, knowing pressure gradient between A and LV (transaortic gradient) and between LV and LA (trans mitral gradient), we can measure blood pressure in A with a non-invasive central blood pressure (BP) analysis device and then we can derive pressure in LA. With the model described, we derive the equation PCWP ≈ {[(systolic central BP + 4 maximal aortic valve outflow velocity2) − 4 maximal mitral valve regurgitation jet velocity2] + [(diastolic central BP − 4 telediastolic aortic valve regurgitation jet velocity2) + mean mitral valve inflow gradient]} / 2. Herein, we propose a new model for PCWP determination using Doppler echocardiography and a non-invasive central blood pressure (BP) analysis device. One of the main advantages of the method we proposed is that, given it is based on a simple physical model instead of multilinear regression, it should be applicable to any class of patient, provided they present some level of aortic and mitral regurgitation. Further studies are needed for its validation by parallel analysis using invasive methods.

Distinct pressure half-time values by transthoracic echocardiography for grading of paravalvular regurgitation after transcatheter aortic valve replacement

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = −0.293; p = 0.138) than in patients without LVH (r = −0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.

Pure Aortic Regurgitation in Pediatric Patients

Aortic regurgitation (AR) continues to be an important cause of morbidity and mortality in pediatric patients. Although echocardiographic parameters are well established for the adults, there are no clear cut-off values for AR severity in children. Cardiac magnetic resonance (CMR) imaging is considered a "gold standard" for a quantitative evaluation of the AR, but it is not widely available. This study assesses which echo parameter can accurately define AR severity as assessed by CMR in pediatric patients. A total of 27 pediatric patients (12 ± 3 years, range 6 to 18 years) with different degree of AR underwent echo assessment within an average of 35 days from CMR. CMR included phase-contrast velocity-encoded imaging for the measurement of regurgitant fraction (RF). Severe AR was defined as RF >33%. Echo evaluation included vena contracta, pressure half time, the ratio between the AR jet and the left ventricular outflow tract diameter (jet/left ventricular outflow tract), presence of holodiastolic reversal flow in abdominal aorta, the ratio between the velocity-time integral of the reversal flow over the forward flow in descending aorta (echoRF). Among the studied parameters, the strongest predictor of severe AR, as assessed by CMR, was echoRF. Receiver-operating characteristic curve showed, for a cutoff >0.38, an area under the curve of 0.886 (p <0.0001), a sensitivity of 71%, and a specificity of 100%. Correlation coefficient between echoRF and RF was R = 0.929 (p <0.0001). In conclusion, echoRF is a strong echo-Doppler marker of severe AR in the pediatric population. This parameter should be routinely added in the standard echo evaluation of pediatric patients with AR.

A Case of Severe Aortic Regurgitation Caused by Fissured Aortic Cusps Reconstructed with Autologous Pericardium

An 82-year-old woman was hospitalised in our institution because of worsening dyspnoea on effort. She had a history of aortic valve reconstruction with autologous pericardium (AVrC) for severe aortic stenosis 1 year and 9 months ago. Her transthoracic echo examination revealed that she had severe aortic regurgitation with preserved left ventricular systolic function. Compared with her previous echo findings shortly after AVrC, her left ventricle was clearly dilated with newly detected moderate mitral regurgitation. Transoesophageal echo was performed for further investigation, which showed that, in particular, her right coronary cusp (RCC) was obviously prolapsed toward the left ventricular outflow tract with wide aortic regurgitant jet. After conservative medical therapy, aortic valve replacement and mitral annular plasty were performed. Her removed autologous aortic cusps clarified the details: not only did the RCC, but also left coronary cusp have two clefts on both ends of each cusp, and the non–coronary cusp had one fissure on one end. Her symptoms improved dramatically after aortic valve replacement. Aortic valve reconstruction with autologous pericardium is characterised by excellent valvular durability with a low mortality. However, the patient in this case suffered from rapid deterioration of the reconstructed autologous aortic valve. According to a previous report, one AVrC case was required reoperation due to aortic regurgitation caused by prolapse of RCC, which was the same cusp as in this case. Autologous RCC for AVrC is usually the smallest and made from thinner side of pericardium. This may be the reason why RCC is the culprit cusp when aortic regurgitation occurs shortly after AVrC.

Assessment of paravalvular leakage after transcatheter aortic valve implantation: add clinical signs to echocardiographic data

A 62-year-old male with pulmonary fibrosis and aortic valve stenosis underwent TAVI (Corevalve Evolut XL 34 mm) in the build-up for lung transplantation (LuTx). Following post-dilation for a large annular perimeter, moderate paravalvular aortic regurgitation (AR) was observed (Video 1). After 6 weeks, he was admitted to the ICU with respiratory failure (Fig. 1A). TTE demonstrated residual mild AR (based on a small excentric paravalvular AR jet, <10% circumferential extent, pressure half-time was not reliably measured) and together with borderline elevated NT-pro-BNP, the consultant cardiologist authorized LuTx listing.However, an abnormal radial arterial pressure waveform was noticed (Fig. 1B). Femoral artery Doppler ultrasound demonstrated holo-diastolic backflow (Duroziez’s sign, Fig. 1C), which may indicate severe AR. Repeat biplane TTE confirmed 30% circumferential paravalvular AR (Fig. 1D, Videos 2 and 3) and descending aorta end-diastolic flow reversal >20 cm/s (Fig. 1E), consistent with the diagnosis.The patient deteriorated rapidly. Given the shortage of donor organs, the option of LuTx after ECMO-assisted paravalvular leak closure (with unpredictable result) was deemed inappropriate. He died and autopsy was done (Fig. 1F).Assessment of the severity of AR after TAVI is challenging. Determination of the circumferential extent of paravalvular AR assessed by TTE is regarded ‘critical’, but may be difficult (1, 2, 3, 4). Although transoesophageal echocardiography may be the default technique in case of uncertainty, this was impossible since this would have required mechanical ventilation, which can be very challenging in end-stage pulmonary fibrosis. In conclusion, clinical signs together with all possible echocardiography views are paramount for the diagnosis.

Effect of aortic regurgitant jet direction on mitral valve leaflet remodeling: a real-time three-dimensional transesophageal echocardiography study

Chronic aortic regurgitation (AR) induces mitral valve (MV) leaflet enlargement, although, its mechanism still remains unclear. This study aimed to clarify the influence of AR jet directions on the MV apparatus in patients with chronic AR. This study included 69 consecutive patients with severe chronic AR and 17 controls who underwent three-dimensional (3D) transesophageal echocardiography (TEE). The anterior mitral leaflet (AML), posterior mitral leaflet (PML) and MV annulus areas were measured at mid-diastole. All AR patients were classified into the posterior (Group A, n = 38) or non-posterior (Group B, n = 31) group based on the AR jet directions. Both two groups revealed the increased total leaflet areas compared with the controls. No significant differences in the left ventricular volumes, PML or MV annulus area were observed between Group A and B; however, Group A had the larger AML area and greater AML/PML area ratio than Group B (both P < 0.01). The multivariate analysis indicated that the posterior AR jet was independently associated with the AML/PML area (P < 0.01). 3D TEE depicted geometric differences in the MV apparatus between the different types of AR jet directions. These results may be helpful in understanding the mechanism of MV leaflet remodeling in chronic AR.

Mitral valve aneurysms: Clinical characteristics, echocardiographic abnormalities, and possible mechanisms of formation.

Mitral valve aneurysms (MVA) are most frequently associated with endocarditis. Echocardiography is the method of choice for diagnosis, and color flow imaging is an important, easy method to detect MVA ruptures. We aimed to study the clinical and echocardiographic findings and their relation to the mechanism of aneurysm formation. We reviewed clinical and echocardiographic records of 18 patients during a 17-year period, corresponding to 0.02% of the total studies performed at our institution. All patients underwent transthoracic echocardiogram (TTE), and all except two underwent transesophageal echocardiogram (TEE). The aneurysm was located either on the anterior leaflet (16 cases) or on the posterior leaflet (two cases). In seven cases, the probable aneurysm formation mechanism was an aortic regurgitant jet striking the anterior mitral leaflet. Perforation was present in 17 (94.4%) patients, and 10 (55.5%) cases presented more than one aneurysm. No patients underwent surgery exclusively because of the echocardiography finding. Different etiologies and formation mechanisms can occur in MVA. Echocardiography plays a fundamental role, providing meticulous examination of the mitral valve anatomy and flow. Unlike standard recommendations, clinical management is possible, and diagnosis does not imply immediate surgical correction.

Clinical Cases: Valvular heart disease142A sub-aortic valve mass in a rheumatoid arthritis patient: an unconventional mechanism of aortic regurgitation143Symptomatic severe aortic regurgitation with coronary obstruction due to chronic type a dissection144Mitral valve prolapse and ventricular tachycardia: a long-lasting love story

Clinical Cases: Valvular heart disease142A sub-aortic valve mass in a rheumatoid arthritis patient: an unconventional mechanism of aortic regurgitation143Symptomatic severe aortic regurgitation with coronary obstruction due to chronic type a dissection144Mitral valve prolapse and ventricular tachycardia: a long-lasting love story