Extracardiac Pathology Research Articles

Robotic cardiac surgery in Brazil.

Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil. From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy. The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term. Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.

Prenatal Diagnosis of the Criss-Cross Heart

We sought to describe the prenatal features and postnatal outcomes of the "criss-cross heart" (CCH) with crossing atrioventricular connections as encountered in 5 cases and to review the literature regarding fetal diagnoses of this lesion. We reviewed the clinical history and fetal echocardiograms of 5 patients with a diagnosis of CCH encountered in our institution from 2010 to 2015. Affected pregnancies were identified through the University of Alberta fetal cardiology database. Fetal and postnatal echocardiograms, prenatal and postnatal clinical records, autopsy, and surgical reports were reviewed. Over the past 5years, major fetal congenital heart disease was identified in 448 pregnancies in the province of Alberta. Of these, 5 had CCH. All 5 were referred for suspected congenital heartdisease, and none had significant extracardiac pathology. Detailed methodical 2-dimensional and color Doppler fetal echocardiography defined the complex diagnoses that were subsequently confirmed postnatally (n= 4) and at fetal autopsy (n= 1). Prenatal diagnosis correctly predicted postnatal presentation and outcomes in 1 with double outlet right ventricle and coarctation, 2 presenting with complete (D) transposition of the great arteries physiology, and 1 presenting as corrected (L) transposition. Three required singleventricle palliation and 1 underwent an arterial switch procedure. In conclusion, detailed evaluation of fetal CCH can result in correct anatomical and pathophysiological diagnoses. It demands a full understanding of the anatomy and pathophysiology to predictaccurately the presentation at birth for accurate counseling and planning perinatal management.

Treating Heart Failure with Preserved Ejection Fraction Related to Arterial Stiffness. Can we Kill Two Birds With One Stone?

Heart failure with preserved ejection fraction (HFpEF). Arterial hypertension (AH), arterial stiffness (AS), older age, and female gender are the main determinants of HFpEF, but several cardiac or extra-cardiac pathologies are also possible causes. The combined ventricular-vascular stiffening (abnormal left atrium-left ventricle coupling related to AS) is the main contributor of the increased prevalence of HFpEF in elderly persons, particularly elderly women, and in younger persons with AH. The hospitalization and mortality rates of HFpEF are similar to those of heart failure with reduced EF (HFrEF). However, although the prognosis of HFrEF has been substantially improved during the last 2 decades, the effective treatment of HFpEF remains an unmet need. Regimens effective in HFrEF have no substantial effect on HFpEF, because of different pathophysiologies of the 2 syndromes. Pipeline drugs seem promising, but it will take some years before they are commercially available. Aggressive treatment of noncardiac comorbidities seems to be the only option at hand. Treatment of anaemia, sleep disorders, chronic kidney disease (CKD), non-alcoholic fatty liver (NAFLD), atrial fibrillation, diabetes, and careful use of diuretics to reduce preload are effective to some degree. Statin treatment, despite the presence of dyslipidaemia, deserves special attention because it has been proven, mainly in small studies or post hoc analyses of trials, that it offers a substantial improvement in quality of life and a reduction in mortality rates. We need to urgently utilize these recourses to relieve a considerable part of the general population suffering from HFpEF, a deadly disease.

Prenatal detection of structural cardiac defects and presence of associated anomalies: a retrospective observational study of 1262 fetal echocardiograms.

The aim of this study is to document the detection of fetal congenital heart defect (CHD) in relation to the following: (1) indication for referral, (2) chromosomal and (3) extracardiac abnormalities. All fetal echocardiograms performed in our institution from 2007 to 2011 were reviewed retrospectively. Indication for referral, cardiac diagnosis based on the World Health Organization International Classification of Diseases tenth revision criteria and the presence of chromosomal and extracardiac defects were recorded. Of 1262 echocardiograms, 287 (22.7%) had CHD. Abnormal anatomy scan in pregnancies originally considered to be at low risk of CHD was the best indicator for detecting CHD (91.2% of positive cardiac diagnoses), compared with other indications of family history (5.6%) or maternal medical disorder (3.1%). Congenital anomalies of the cardiac septa comprised the largest category (n = 89), within which atrioventricular septal defects were the most common anomaly (n = 36). Invasive prenatal testing was performed for 126 of 287 cases, of which 44% (n = 55) had a chromosomal abnormality. Of 232 fetuses without chromosomal abnormalities, 31% had an extracardiac defect (n = 76). Most CHDs occur in pregnancies regarded to be at low risk, highlighting the importance of a routine midtrimester fetal anatomy scan. Frequent association of fetal CHD and chromosomal and extracardiac pathology emphasises the importance of thorough evaluation of any fetus with CHD.

Current Role of Cardiac and Extra-Cardiac Pathologies in Clinically Indicated Cardiac Computed Tomography with Emphasis on Status Before Pulmonary Vein Isolation

The aim of this study was to assess the incidence of cardiac and significant extra-cardiac findings in clinical computed tomography of the heart in patients with atrial fibrillation before pulmonary vein isolation (PVI). 224 patients (64 ± 10 years; male 63 %) with atrial fibrillation were examined by cardiac 64-slice multidetector CT before PVI. Extra-cardiac findings were classified as "significant" if they were recommended to additional diagnostics or therapy, and otherwise as "non-significant". Additionally, cardiac findings were documented in detail. A total of 724 cardiac findings were identified in 203 patients (91 % of patients). Additionally, a total of 619 extra-cardiac findings were identified in 179 patients (80 % of patients). Among these extra-cardiac findings 196 (32 %) were "significant", and 423 (68 %) were "non-significant". In 2 patients (1 %) a previously unknown malignancy was detected (esophageal cancer and lung cancer, local stage, no metastasis). 203 additional imaging diagnostics followed to clarify the "significant" findings (124 additional CT, costs 38 314.69 US dollars). Overall, there were 3.2 cardiac and 2.8 extra-cardiac findings per patient. Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p <0.05). Cardiac CT scans before PVI should be screened for extracardiac incidental findings that could have important clinical implications for each patient.

Computed tomography angiography of coronary artery bypass grafts: robustness in emergency and clinical routine settings

There is a high probability for presence of irregular heart rates and artifacts in patients with previous coronary artery bypass graft (CABG) surgery. Previously reported diagnostic performance of ECG-gated 64-slice dual-source computer tomography angiography (CTA) in this patient group is based on pre-selection for normal heart rate and routine clinical setting. To investigate image quality and diagnostic performance of CTA in patients with previous CABG surgery in various clinical settings. Fifty-six non-selected, consecutive patients (110 grafts, 44 arterial, 66 venous) with previous CABG surgery were prospectively examined using a dual-source 64-slice CT (Siemens Definition, Forchheim, Germany) without utilization of CT-related pharmaceutical heart rate control. Patients were stratified according to the clinical setting: planned redo-cardiac surgery; emergency CTA within 30 days after CABG surgery; routine follow-up after CABG surgery. A reference standard was available for 30 patients (53.6%; 67/110 grafts). Image quality, artifacts, and graft patency were independently assessed by two observers. All CTAs were diagnostic despite the presence of irregular heart rhythm (25% of cases) and artifacts (72.7% of grafts). CTA was accurate in all patient groups in assessing graft patency (97.9% sensitivity; 100% specificity; 98.5% accuracy) but artifacts decreased diagnostic performance for stenosis detection (60% sensitivity; 88.6% specificity; 84.1% accuracy). Arterial grafts exhibited more surgical clip artifacts compared to venous grafts, which predominantly showed motion artifacts. Overall diagnostic quality was rated excellent in 70.9%/56.4%, good in 23.4%/39.1%, and sufficient in 5.5%/4.5% by each observer, respectively. CTA detected acute findings in 10 cases (graft bleeding, graft occlusion, pericardial hematoma, sternal instability with retrosternal abscess formation, pericardial effusion, left ventricle thrombus) in the emergency group; seven cases required surgical revision. Dual-source CTA is a robust and accurate method for assessment of graft patency and detection of relevant extra-cardiac pathologies in a non-selected patient population after CABG surgery in routine as well as emergency clinical settings. Artifacts caused by irregular heart rhythm or surgical clips do not impair graft patency evaluation but limit stenosis assessment.

Aortic Valve Replacement in Elderly Patients: Need of Multidiscinary Complementary Procedures

Until the decade of 1980-1990 cardiac surgery was considered an exceptional option in octogenarian patients. This conservative attitude for elderly subjects, considered to be at high risk for frequent associated extracardiac pathologies, was progressively modified thanks to the progress observed in different medical and paramedical specialties. Objectively, there was a positive evolution of cardiovascular diagnostic procedures, anesthetic, surgical and intensive care techniques, including biomarkers and new drugs. Concomitantly, the extracorporeal circulation material was perfected and new methods of circulatory assistance and myocardial protection were created. Finally, knowledge of valve prosthesis long term results led to a change in the attitude of the medical community towards cardiac surgery in octogenarian patients. (1, 2) Valve diseases in elderly patients are mainly represented by severe calcified aortic valve stenosis. Mitral valve diseases, usually degenerative mitral insufficiency, are rarer. The prognosis of the spontaneous evolution of severe aortic stenosis is death in the short term since onset of symptoms as heart failure, angina, syncope and acute pulmonary edema. Surgery is indicated in the face of this spontaneous evolution. A bioprosthesis is recommended after 70 years of age to reduce the frequency of thromboembolic or hemorrhagic complications, and according to its theoretical durability it may not surpass the patient s lifetime. The problem of a reintervention due to tissue deterioration is always a possibility, but of less magnitude in elderly patients. As shown by the work by Pipkin et al. (3) at the Hospital Universitario Fundacion Favaloro, the evolution of surgical techniques and postoperative care currently enables aortic valve replacement surgery in an important part of the population represented by octogenarian patients who suffer from an invalidating cardiomyopathy with bad prognosis despite medical treatment. Surgical risk is not negligible, so there should be great precision in the careful selection of surgical candidates, with the help of the geriatrician. Patients not presenting associated pathologies susceptible of considerably increasing surgical risk and post-

Multidetector Computer Tomography in Congenital Heart Disease

Multidetector Computer Tomography in Congenital Heart Disease Objectives: Extracardiac pathology is common in patients with congenital heart disease. Multidetector computer tomography can be a useful tool for detection. To date, there are only scarce reports regarding “incidental“ non-cardiac findings during cardiac computer tomography. Aims of this study were to analyze indications, implementation, and timing of multidetector computer tomography in patients with congenital heart disease. Materials and methods: During 32 months, 195 patients were retrospectively included in our analysis. Type of congenital heart disease, timing of the procedure (preoperative, postoperative, follow-up, native), explored areas (thorax, cranium, abdomen, sternum, neck and extremities), and indications were disclosed. Results: During the study period, 250 scans were performed in 195 patients. Mean age was 23.0 ± 17.1 years (minimum 3 days, maximum 73 years); 48.2% were younger than 20 years. Almost 71% had undergone reparative cardiovascular surgery. Complex congenital heart disease (26.5%) and left-ventricular heart obstructions (22.5%) were the most common defects referred to computer tomography. In 19.5% of patients more than one scan was necessary. The tests were most performed in the postoperative/ postinterventional (36%) and long-term follow-up (30.4%) periods. Most indications focused on the thorax (55.5%), particularly when cardiovascular complications were suspected. Assessment of cerebral pathology was the second most frequent indication (25%). Final diagnosis was achieved in 94% of cases. Conclusions: Extracardiac pathology is frequent in patients with congenital heart disease, mainly in younger patients and with complex cardiac pathology. Multidetector computer tomography is a very useful tool when cardiovascular complications or cerebral pathology is suspected. Therefore, a good cooperation between radiologists and congenital cardiologists is mandatory.

Stiff Heart and Stiff Arteries. Could We Soften Both?

Old age, female gender, hypertension (HTN), cardiac ischaemia, and arterial stiffness (AS) are the main determinants of a stiff heart, diastolic dysfunction (DD), and finally heart failure with preserved ejection fraction (HFpEF); however, several cardiac or extra-cardiac pathologies may also be involved. The combined ventricular-arterial stiffening (abnormal left ventricle-arterial coupling) is the main determinant of the increased prevalence of HFpEF in elderly persons, particularly women, and in younger subjects with HTN. Hospitalization and mortality rates in patients with HFpEF are similar to those of patients with heart failure with reduced EF (HFrEF). However, although the prognosis of HFrEF has improved over time, the optimal treatment of HFpEF remains unclear, because of the differences in the pathophysiology of the two syndromes. A number of new drugs have shown promise but they will not be commercially available for several years. For the time being, aggressive treatment of non-cardiac comorbidities is the only option available for the management of HFpEF. Treatment of anaemia, sleep disorders, chronic kidney disease, non-alcoholic fatty liver disease, atrial fibrillation, diabetes mellitus, and judicious use of diuretics are effective to some degree. Statin treatment deserves special attention, regardless of the presence of dyslipidaemia, because it has been shown, mainly in small studies, post hoc analyses, and in a large recent meta-analysis, that it is related to an improved quality of life and a reduction in HF-related mortality. We urgently need to utilize these recourses to relieve a substantial number of patients suffering from HFpEF, a disease with an ominous prognosis.

Multidetector computed tomographic angiography in evaluation of neonates with suspected extracardiac congenital heart disease: experience in Vilnius University Hospital Santariškių Klinikos

Summary The aim of this study was to determine the frequency of extracardiac pathology in neonatal patients with suspected congenital heart disease referred to undergo multidetector computed tomography (MDCT) angiography in Vilnius University Hospital Santariskiu Klinikos. The safety of MDCT angiography (intravenous contrast media volume injected, scanning time and exposure to ionising radiation) was also evaluated. Patients and Methods: During the period of 2006-2012, in Vilnius University Hospital Santariskiu Klinikos 186 pediatric patients were referred to undergo MDCT angiography of whom 71 were neonates with suspected complex congenital heart disease (CHD) and extracardiac pathology. Results: Sixty nine (97.2%) of referred neonates were found to have extracardiac pathology (36 had extracardiac vascular pathology only, 4 - extracardiac non-vascular pathology only and 29 - both extracardiac vascular and non-vascular pathology). In 47 patients diagnosis of extracardiac pathology was verified intraoperatively. Remainder (n = 24) of the group were not operated (12 patients died because of hemodynamic instability and inoperable complex CHD, 9 patients were scheduled for later surgery, in 3 patients surgery was not indicated). Mean contrast media volume used was 4.18±1.03 ml, mean scanning time was 1.07±0.77 s and mean effective radiation dose was 2.8± 0.69 mSv. No adverse reactions or complications were observed. Conclusions: MDCT angiography is accurate and safe method in diagnosis of complex congenital heart disease with extracardiac pathology.

Cirurgia robótica em Cardiologia: um procedimento seguro e efetivo

ABSTRACTObjective:To evaluate the short and medium-term outcomes of patients undergoing robotic-assisted minimally invasive cardiac surgery.Methods:From March 2010 to March 2013, 21 patients underwent robotic-assisted cardiac surgery. The procedures performed were: mitral valve repair, mitral valve replacement, surgical correction of atrial fibrillation, surgical correction of atrial septal defect, intracardiac tumor resection, totally endoscopic coronary artery bypass surgery and pericardiectomy.Results:The mean age was 48.39±18.05 years. The mean cardiopulmonary bypass time was 151.7±99.97 minutes, and the mean aortic cross-clamp time was 109.94±81.34 minutes. The mean duration of intubation was 7.52±15.2 hours, and 16 (76.2%) patients were extubated in the operating room immediately after the procedure. The mean length of intensive care unit stay was 1.67±1.46 days. There were no conversions to sternotomy. There was no in-hospital death or deaths during the medium-term follow-up. Patients mean follow up time was 684±346 days, ranging from 28 to 1096 days.Conclusion:Robotic-assisted cardiac surgery proved to be feasible, safe and effective and can be applied in the correction of various intra and extracardiac pathologies.

Severe left heart obstruction with retrograde arch flow influences fetal cerebral and placental blood flow

Decreased middle cerebral artery (MCA) pulsatility index (PI) is a marker of fetal brain-sparing in placental insufficiency and it is also found in fetuses with severe congenital heart disease. This study sought to explore the impact of anatomical subtypes in fetal heart disease on MCA-PI and head growth. We retrospectively reviewed fetal echocardiograms of pregnancies complicated by fetal hypoplastic left heart syndrome (HLHS; n = 42) with and without anatomic coarctation (n = 28 and n = 10, respectively), isolated severe aortic coarctation (n = 21), D-transposition of the great arteries (TGA; n = 11) and pulmonary outflow tract obstruction without forward flow across the pulmonary valve (POTO; n = 15), comparing observations with gestational age-matched controls (n = 89). No fetus had major extracardiac pathology or aneuploidy. MCA and umbilical artery (UA) PI, the cerebral placental ratio (CPR = MCA-PI/ UA-PI) and neonatal head circumference were obtained and expressed as Z-scores. Lower MCA-PI, higher UA-PI and lower CPR were observed in fetal HLHS and isolated coarctation with reversed arch flow (n = 6) (P < 0.001) but not TGA, POTO or isolated coarctation with antegrade arch flow (n = 15) compared with controls. No difference was found between HLHS with anatomical coarctation and those without; however, MCA-PI correlated positively with neonatal head circumference in HLHS with reversed distal arch flow (r = 0.33, P < 0.05). Severe left heart obstruction with reversed aortic arch flow is associated with altered fetal cerebral blood flow, and in these conditions, MCA-PI positively correlates with head growth. Anatomical arch obstruction itself may not be a contributing factor to altered MCA flow in fetal HLHS.

Cardiac and extra-cardiac pathologies in patients undergoing clinically indicated cardiac computed tomography

Cardiac and extra-cardiac pathologies in patients undergoing clinically indicated cardiac computed tomography

Prevalence and clinical relevance of extra-cardiac findings at cardiac magnetic resonance imaging

Ziele: The aim of this study was to assess the incidence of extra-cardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart including surrounding structures and to determine the influence of those findings on patient's management. Methode: N = 854 patient studies (median age 58 ± 12 years, male 63%) were included and examined by 1.5 Tesla (T) MR to primarily analyze the cardiac anatomy and secondly the surrounding structures. Extra-cardiac findings were classified as significant (Group A) if they were recommended to additional diagnostics or therapeutical interventions and as non-significant if there was no influence on patient's management (Group B). Ergebnis: 631 patient studies were free of any kind of extra-cardiac pathologies. In the remaining cases, 286 extra-cardiac findings were examined. There were –0.33 extra-cardiac findings per patient. 49 were defined as significant (Group A) and 237 as non-significant findings (Group B). The most common Group A findings were suspicious pulmonary nodules or masses > 4 mm diameter (n = 14) and aortic aneurysms (n = 5). In Group B, most of the findings were hepatic cysts or hemangiomas (n = 50), followed by renal cysts (n = 47). 8 malignancies were certainly observed. The most frequent indication for CMRI was evaluation of cardiac stress ischemia (n = 501, 59%). Schlussfolgerung: Extra-cardiac findings in clinical CMRI are common in patients referred to CMRI (26%). Radiologists and cardiologists have to be aware of relevant extra-cardiac findings which might require additional diagnostics or treatment. There is an importance of paying appropriate attention to structures outside of the heart.

Prevalence and clinical relevance of extracardiac findings at cardiac MRI

To assess the incidence of extracardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart, and to determine the influence of those findings on patient management. During 40 months, 854 CMRI were performed at 1.5 T. Extracardiac findings were classified as significant (group A), if recommended for additional diagnostics or therapeutic interventions, and as nonsignificant (group B). The most frequent indication for CMRI was evaluation of cardiac stress ischemia. In all, 631 CMRI (74% of 854) showed no extracardiac pathologies. In the remaining 223 CMRI (26% of 854), a total of 286 extracardiac findings were detected. Among these findings, 49 were considered significant (group A) and 237 nonsignificant (group B). In group A, the most common findings were suspicious pulmonary nodules or masses. In group B, the most frequent findings were hepatic cysts or hemangiomas. Eight malignancies were observed with certainty at CMRI. Seven of them had been incidentally diagnosed on CMRI for the first time, and subsequently changed the patients' management. Extracardiac findings in clinically indicated CMRI are common (about 26%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment.

Letter to the Editor Rare cardiovascular anomaly: congenital unilateral absence of the pulmonary artery

Letter to the Editor Rare cardiovascular anomaly: congenital unilateral absence of the pulmonary artery

Prevalence and clinical relevance of extra-cardiac findings at cardiac magnetic resonance imaging

Background The aim of this study was to assess the incidence of extra-cardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart including surrounding structures and to determine the influence of those findings on patient’s management. Methods N=854 patient studies (median age 58 ± 12 years, male 63%) were included and examined by 1.5 Tesla (T) MR to primarily analyze the cardiac anatomy and secondly the surrounding structures. Extra-cardiac findings were classified as significant (Group A) if they were recommended to additional diagnostics or therapeutical interventions and as non-significant if there was no influence on patient’s management (Group B). Results 631 patient studies were free of any kind of extra-cardiac pathologies. In the remaining cases, 286 extra-cardiac findings were examined. There were ~0.33 extracardiac findings per patient. 49 were defined as significant (Group A) and 237 as nonsignificant findings (Group B). The most common Group A findings were suspicious pulmonary nodules or masses > 4 mm diameter (n=14) and aortic aneurysms (n=5). In Group B, most of the findings were hepatic cysts or hemangiomas (n=50), followed by renal cysts (n=47). 8 malignancies were certainly observed. The most frequent indication for CMRI was evaluation of cardiac stress ischemia (n=501, 59%). Conclusions Extra-cardiac findings in clinical CMRI are common in patients referred to CMRI (26%). Radiologists and cardiologists have to be aware of relevant extra-cardiac findings which might require additional diagnostics or treatment. There is an importance of paying appropriate attention to structures outside of the heart.

GDF‐15 in heart failure: providing insight into end‐organ dysfunction and its recovery?

GDF‐15 in heart failure: providing insight into end‐organ dysfunction and its recovery?

Diagnosis of Tetralogy of Fallot and Its Variants in the Late First and Early Second Trimester: Details of Initial Assessment and Comparison with Later Fetal Diagnosis

We sought to evaluate the completeness of echocardiographic diagnosis of fetal tetralogy of Fallot (fTOF) at 12-17 weeks gestation, and compare assessment and clinical outcomes to diagnoses made at >17 weeks gestation. We identified all fTOF diagnoses made in our experience from 2003 to 2008. Referral indication, anatomic detail by echocardiography and pregnancy outcomes were compared between fetuses diagnosed at ≤ 17 weeks (Group I) and >17 weeks gestation (Group II). A 10-point scoring tool was applied retrospectively to the echocardiograms at initial diagnosis (1 point each was ascribed to visualization of right ventricular outflow obstruction, pulmonary valve, pulmonary arteries including dimensions, pulmonary arterial flow, systemic and pulmonary venous anatomy, atrioventricular valves, ductus arteriosus, ductus flow, aortic arch morphology, sidedness and flow). There were 10 pregnancies in Group I (12-17 weeks) and 25 in Group II (mean gestation at diagnosis 23.5 ± 5.7). The most common reason for referral was extracardiac pathology in Group I (80%) and suspected fetal heart disease on obstetric ultrasound in Group II (64%). Transabdominal imaging was adequate in about half of Group I studies. Mean anatomic diagnosis score in Group I was 6.1(range 2.5-9) and Group II was 8.4 (range 6.5-10). Elective pregnancy termination occurred in 80% in Group I and 33% in Group II. fTOF can be diagnosed in first and early second trimesters with detailed anatomic assessment possible in most. Referral indication and pregnancy outcome differ considerably between early and later prenatal diagnosis of fTOF.

Acute intrathoracic intestinal strangulation diagnosed by transthoracic echocardiography

Transthoracic echocardiography plays a central role in diagnosing a variety of cardiac and pericardial disorders. However its use in identifying extra-cardiac thoracic pathology is less well recognised. We describe an unusual case of intrathoracic intestinal strangulation detected by transthoracic echocardiography. The recognition of bowel loops within the left hemithorax enabled rapid confirmatory computed tomographic imaging and subsequent life-saving surgery. This case demonstrates the utility of bedside echocardiography in the assessment of intrathoracic pathology and emphasises the need for cardiologists to be familiar with the echocardiographic appearance of these disorders.