Moderate Dilatation Research Articles

Renal pelvic dilation

Renal pelvic dilation

Hydroureter

Hydroureter

Study of patients with Pseudoexfoliation syndrome undergoing cataract surgery

To analyze the visual outcome in patients with pseudoexfoliation and to know the surgical parameters to cogitate in patients with pseudoexfoliation syndrome. An Observational study which was conducted in the Ophthalmology department in a tertiary care hospital in a rural area from June 2019 to December 2019. A total of 52 eyes of 52 patients aged 40 years and above, of either sex, clinically diagnosed with senile cataract and associated with pseudoexfoliation were enrolled in the study. After assessing best corrected visual acuity (BCVA), a detailed anterior and posterior segment examination was performed along with lacrimal sac syringing, manual keratometry, contact A-scan biometry and intraocular lens (IOL) power was calculated. All patients underwent manual small incision cataract surgery under peribulbar anaesthesia and intraocular lens was implanted. Intraoperative complications were noted during the surgery and was reported .Best corrected visual acuity was recorded on day 1, at 1week and at 1 month of follow up. Out of 52eyes of 52 patients, 29 were females (55.76%) and 38 eyes (73.07%) exhibited bilateral involvement. Distribution of the PXF material in various ocular structures was observed and majority of them (36.53%) had PXF material equally in iris, pupillary margin and lens. Based on the morphology of cataract associated with psudoexfoliation, nuclear cataract was the most commonly observed in 16 eyes (30.76%) and 42 eyes (80.76%) had moderate pupillary dilatation. The intraoperative difficulties observed during cataract surgery was poor pupillary dilatation which was managed by controlled sphincterotomy during the surgery in 3 eyes (5.76%), Iridiodialysis, rhexis extension, zonular dialysis each in 1 eye and posterior capsular rent in 2 eyes. Around 92.30% of the total study population achieved post-operative BCVA of 6/12 or better at 1month of follow up. Decreased visual acuity was noted in 2 (3.84%) eyes due to persistent corneal edema, one eye (1.92%) had posterior capsular opacification and one eye (1.92%) had cystoid macular edema. This study concludes that with careful preoperative assessment and necessary intraoperative precautions, good visual outcome can be achieved in patients with cataract with pseudoexfoliation.

A Case of Isolated Bicuspid Pulmonic Valve and Pulmonary Artery Aneurysm.

A 33-year-old woman with a history of thyroid surgery for thyroid cancer and radioactive iodine therapy was referred for echocardiography due to dyspnea on exertion. Transthoracic echocardiography showed normal left ventricular size and function (the ejection fraction = 55%), a prolapsing mitral valve with redundant chordae, mild mitral regurgitation, a tricuspid aortic valve, mild aortic insufficiency, and mild tricuspid regurgitation. The most remarkable echocardiographic findings were moderate right ventricular dilation with mild systolic dysfunction, moderate right atrial dilation, an aneurysmal pulmonary artery (the main pulmonary artery = 47 mm), mild pulmonary stenosis (the peak gradient = 22 mmHg), and severe pulmonary regurgitation (the vena contracta = 6–7 mm and the pressure half time = 105 ms). Transesophageal echocardiography with the use of 3D modalities demonstrated a bicuspid pulmonic valve with doming and poor coaptation of the pulmonic valve leaflets (Figure 1). Additionally, a large patent foramen ovale was visualized in color Doppler (the flap separation = 2 mm and the tunnel length = 11 mm) with bubble passage in agitated saline injection. Bicuspid pulmonic valves constitute a rare finding, and they are most often associated with other congenital heart diseases. Isolated bicuspid pulmonic valves are extremely rare, with an incidence rate of about 0.1% in clinical practice.1 Pulmonary artery aneurysms also comprise a rare abnormality, with an incidence rate of approximately 1 in 14 000 cases in most studies.2 The association between bicuspid pulmonic valves and pulmonary artery aneurysms has been reported, and the pathophysiologic causes of this association include hemodynamic alterations due to bicuspid pulmonic valves and most likely the abnormal migration of neural crest cells.3 The diagnosis of a bicuspid pulmonic valve by 2D imaging is challenging and sometimes impossible. Using 3D echocardiography and reconstruction confers a better assessment of the pulmonic valve morphology and identification of bicuspid pulmonic valves.

Outcome of Pulmonary Autograft After the Ross Procedure.

The purpose of this study was to assess autograft function after the Ross procedure and to review surgical outcomes associated with autograft reoperations. This is a retrospective study of patients undergoing the Ross procedure since 1993. Autograft function and autograft reoperation were studied. Autograft failure was defined as more than moderate autograft regurgitation or autograft dilatation to more than 50 mm diameter or z-score of more than +4 in children. One hospital death was excluded from analysis as were patients with unknown late autograft status. Among 75 patients analyzed, preoperative diagnosis before the Ross procedure included aortic regurgitation in 26, aortic stenosis in 19, combined lesions in 28, and 2 mechanical valve malfunctions. Median age at the Ross procedure was 12.1 (0.4-43.6) years with 44 children less than 15 years old. Six patients had greater than mild autograft regurgitation at post-Ross hospital discharge. During median follow-up of 14.9 years, there were 23 autograft failures. Eighteen autograft reoperations were performed on 17 patients (13 children), including 12 aortic valve replacements, 5 aortic root replacements (including 1 valve-sparing root replacement), and 1 Konno procedure. Freedom from autograft failure and autograft reoperation at 20 years after the Ross procedure was 52.0% and 66.3%, respectively. Multivariate analysis identified greater than mild autograft regurgitation at hospital discharge from Ross procedure as a risk factor for autograft failure (P < .01). All patients who underwent autograft reoperation survived and had good health status at a median of 6.9 years after the reoperation. The Ross procedure is effective in delaying prosthetic aortic valve replacement, although the time-related risk of autograft failure is a real consideration.

Coronary Disease Risk in Asymptomatic Patients with Left Ventricular Moderate Dilatation

Goal of the Study is to assess the risk of coronary disease of asymptomatic ischemia in patients with left ventricular moderate dilatation. Methods: The work was based on the results of investigation of 185patients with left ventricular moderate dilatation, aged 35-55 years from the “Tbilisi Heart and Vascular Clinic” contingent. Among them, there are 159 men and 26 women. Results: Patients who suffer from left ventricular moderate dilatation and don’t expose typical symptom of ischemia possibly are in risk of carrying damaged coronary artery. the LV moderate dilatation of the left ventricle can be used for primary diagnosing of silent ischemia. Sensitivity - 0.867(95%CI:0.806-0.927); Specificity – 0.800(95%CI:0.703-0.897); Prognostic value of positive results; 0.889(95%CI:0.832-0.946); Prognostic value of negative results - 0.765(95%CI:0.664-0.866); diagnostic value - 0.843(95%CI:0.791-0.896). Conclusions: In patients with silent ischemia, the coronary disease predictors are: left ventricular moderate dilatation, male gender, dyslipidemia, arterial hypertension, smoking, positive treadmill test, ischemic disease in 1st degree relatives, low tolerance to treadmill test. Thus, we can use the moderate dilatation of the left ventricle for the primary diagnosing of silent ischemia. The test is simple and non-invasive. It is characterized by high sensitivity and specificity and can be used for early diagnosing of silent ischemia and the prevention of cardiac cases.

Sonographic Association of Ventriculomegaly and Neural Tube Anomalies

Background: Ventriculomegaly is most common indicator of many of neural tube anomalies of intrauterine fetus. Presence of which has alarming sign for sonologist to have careful evaluation of fetus for other cranial and extra cranial anomalies. Aim: To evaluate the sonographic difference of fetal ventricle dilatation and neural tube anomalies. Study design: Cross Sectional study. Methodology: Female patients (n=1492) were enrolled in present study held at University Ultrasound Clinic, Green Town, University of Lahore as a reference placement for 6 months. Informed consent was taken from all of them. In this study, pregnant women who underwent ultrasound scanning between 18 and 40 weeks of gestational age were reviewed according to normal size of ventricles and dilatation of ventricles by per abdominal ultrasound having convex transducer with 3.5MHZ frequency. Results: A total of 1492 cases of pregnant women between gestational ages of 18-40 weeks were examined. Normal cases were 1485/1492(99.5%).Total 7-cases were found to have ventricle dilatation. Fetus with mild ventricular dilatation 1/7, with moderate ventricle dilatation were 4/7, 2/4 having moderate ventricle dilatation were associated with neural tube anomalies, severe ventricle dilatation was noted in 2/7, both these fetuses had neural tube anomalies. Conclusion: This study concluded that level of degree of dilatation increases the chances of abnormalities. Early detection provide better counseling opportunity for family to make decisions regarding their fetuses. Keywords: Neural tube defects, Ventriculomegaly, Gestation age and Ultrasonography.

Percutaneous Transhepatic Treatment for Obstructing Retained Surgical Biliary Stents After Pediatric Liver Transplantation Without Placement of Biliary Drain

Percutaneous Transhepatic Treatment for Obstructing Retained Surgical Biliary Stents After Pediatric Liver Transplantation Without Placement of Biliary Drain

The value of prenatal magnetic resonance imaging and postnatal follow-up using Gesell Developmental Schedules score for mild-to-moderate simple bilateral fetal ventriculomegaly

Objective To investigate the relationship of mild-to-moderate simple bilateral fetal ventriculomegaly with postnatal neurological development. Methods Cases of simple lateral ventricular dilatation (273) were divided into bilateral mild dilatation (10.0–12.0 mm, 62), bilateral moderate dilatation (12.1–15.0 mm, 29), unilateral mild dilatation (133), and unilateral moderate dilatation (49) groups. The control group comprised 50 normal fetuses. Neurological development was assessed using Gesell Developmental Schedules (GDS) at postnatal 3, 6, 12, and 18 months. Results At postnatal 6, 12, and 18 months, the GDS score was higher for bilateral than for unilateral dilatation (p < .05). At postnatal 3 and 6 months, the GDS score was higher for the bilateral dilatation groups than for the control group (p < .05). At postnatal 6, 12, and 18 months, the GDS score was higher for the bilateral moderate dilatation group than for the unilateral moderate dilatation group (p < .05). Further, at postnatal 3, 6, 12, and 18 months, the GDS score was higher for the bilateral moderate dilatation group than for the control group (p < .05). Conclusion At postnatal month 6, the GDS evaluation results of the bilateral dilatation groups were significantly inferior compared to those of the unilateral dilatation group.

Slit Lamp profile of Pseudoexfoliation eyes

Background: Pseudoexfoliation syndrome is an age-related systemic microfibrillopathy, caused by progressive accumulation and gradual deposition of extracellular grey and white material over various tissues. It is associated with many intraocular abnormalities like poor pupillary dilatation, zonular dehiscence, glaucoma etc. Hence it is important to do detailed slit lamp examination with dilated pupil to detect the pseudoexfoliative deposits in eye, especially in elderly to prevent unforeseen complications.&#x0D; Aims and Objective: To study pattern of distribution of pseudoexfoliative material in eyes with pseudoexfoliation syndrome and to study the dilatation profile of pupil in such eyes.&#x0D; Materials and Methods: This observational study was conducted on patients with pseudoexfoliation syndrome who attended OPD in the Upgraded Department of Ophthalmology, Government Medical College, Jammu from 1st April 2018 for a period of 6 months. The clearance was taken from ethical committee for the study in reference. Informed consent was taken from all the patients enrolled in the study.&#x0D; Results: Pupillary margin was found to be the most common site for deposition of pex material i.e. 51 (75%) patients followed by anterior surface of lens in 32(47.05%) patients. Patients had simultaneous deposition of pex material over various parts of the eye. 64 (94.12%) patients had pex material deposited on pupil or lens. Only 1(1.47%) patient had pex deposits over cornea. 56 (82.35%) patients attained good to moderate dilatation of pupil with 0.8% tropicamide e/d. 12(17.65%) patients had pupillary dilatation of ≤4mm hence poor dilatation.&#x0D; Conclusion: Pseudoexfoliation presents challenges that must be adequately addressed with detailed slit lamp examination. Cases may go undetected due to failure to dilate the pupil or to examine with slit lamp after dilatation. Adequate pre-operative assessment should especially be done before cataract surgery with the aim to identify problems like the possibility of fragile zonules and inadequate mydriasis which could increase intraoperative complications arising from undue manipulations.

Guidelines on Pancreatic Cystic Neoplasms: Major Inconsistencies With Available Evidence and Clinical Practice— Results From an International Survey

Guidelines on Pancreatic Cystic Neoplasms: Major Inconsistencies With Available Evidence and Clinical Practice— Results From an International Survey

Predictores de fibrilación auricular en pacientes con ictus embólico de origen indeterminado

Background and objectivesAtrial fibrillation (AF) detection in patients with embolic stroke of underdetermined source (ESUS) entails a change of medical treatment and a significant decrease in the incidence of new strokes. It is necessary to determine which patients would benefit more from prolonged electrocardiographic monitoring. Our aim was to find electrocardiographic and echocardiographic AF predictors in patients with ESUS. MethodsWe performed a cohort study that included 95 consecutive patients admitted to the hospital because of an ESUS. An electrocardiogram, each subject in the study underwent a 24-hour Holter-electrocardiogram (Holter-ECG) and an echocardiogram. A 2-year follow up was also conducted, with a 24-hour Holter-ECG every 3months for the first year, and every 6months during the second one. ResultsDuring the follow-up, AF was detected in 11 patients (11.6%), with a detection rate of 3.2% at 6months, 7.4% at 12months, and 11.6% at 18months as well as at 24months. The variables that were independently related to AF detection included moderate or severe left atrium dilation (P=.02), interatrial advanced block (P=.04) and more than 1000 premature atrial beats on 24-hour Holter-ECG (P=.01). ConclusionsModerate or severe atrial dilation, interatrial advanced block, and the presence of more than 1000 premature atrial beats on 24-hour Holter-ECG behave as AF predictors in patients with ESUS.

Routine pre-employment echocardiography assessment in young adults: cost and benefits

BackgroundConventional echocardiography is a safe, available, and accurate tool for cardiac structural and functional evaluation, but it should not cancel clinical assessment and history tacking, and indeed both are complementary. A pre-employment assessment is important for employees and community safety and suitability for a specific work requirement.ResultsAiming to assess the value of routine pre-employment echocardiography for the detection of cardiac abnormalities, we examined seven hundred ninety-five persons who were routinely referred to us for pre-employment conventional echocardiography. Only 9 persons had structural cardiac abnormalities (1.3%) and distributed as follows: two had bicuspid aortic valve with isolated aortic regurgitation, one of them had mild AR, and the other had moderate AR. Two cases had mitral valve prolapse, one of them had trivial MR, while the other had a flail anterior leaflet with severe MR. One patient had atrial septal defect 1.5 cm with mild pulmonary hypertension and right-sided chambers dilatation. One patient had dextrocardia (situs inversus totalis) without other cardiac problems. One had moderate pulmonary hypertension and modest right-sided chambers dilation. Two patients had left ventricular hypertrophy. Surprisingly, we did not detect rheumatic valvular heart disease. The money cost of echocardiography tests for those 795 persons was 198,750 Egyptian pounds (LE); their transportation cost was about 19.800LE. The total group time cost of the tests was 265 h, total time lost at the waiting room was 1590 h, total transportation time lose was 2385 h, so the total time cost was about 4000 h. Using psychological stress questionnaire, 33 participants (4.2%) had results suggestive of a low sense of psychological pressure due to echocardiography examination, 221 participants (27.8%) had results suggestive of a moderate feeling of stress, while 541 participants (68%) had results suggestive of a high sense of stress.ConclusionWe recommend against routine echocardiography for cardiac assessment in pre-employment assessment and to do it only for persons with abnormal clinical or ECG findings.

Ultrasonographic and Radiographic Diagnosis of Ectopic Ureter in a Dog

Background: Ureteral ectopia (or ectopic ureter) is a congenital anomaly of the urinary system in which the ureter inserts anywhere other than the vesical trigone. This anatomical change may have unilateral or bilateral involvement. The most evident clinical sign, occurring mostly in females, is urinary incontinence, however in some cases the condition may progress to nephritis and dilation of the renal pelvis. The diagnosis is established through imaging, and definitive treatment requires surgical approach. The present study reports a case of ureteral ectopia in a dog which was diagnosed by ultrasound and contrast radiography (excretory urography) and successfully treated by neoureterostomy.Case: A 10-month-old female American Pit Bull Terrier was attended at the Veterinary Hospital of the Federal Rural University of the Semi-Arid (UFERSA), in Mossoró, RN. Her owner reported incontinence of dark, malodorous urine since birth as the chief complaint. After clinical examination, cystitis was suspected, and a complete blood count, urinalysis, and abdominal ultrasound was requested. The blood count and creatinine were within the reference values. The presence of struvite crystals were found on urinalysis. Ultrasound examination revealed a tortuous, dilated right ureter from the renal pelvis to the urinary bladder; no uroliths were identified as a cause of potential obstruction, but the ipsilateral kidney showed increased cortical echogenicity, loss of corticomedullary definition, and moderate pelvic dilation. These findings supported a presumptive diagnosis of ectopic ureter. For the purpose of confirming this suspicion, excretory urography was performed, revealing unilateral ureteral dilation and radiopaque contrast uptake following the path of the urethra. Once the diagnosis was confirmed, surgery was performed to correct the ureteral ectopia using the standard neoureterocistostomy technique. Considering the unilateral involvement, location of the insertion, and preserved renal function, the decision was made to perform a neoureterostomy. During the surgery it was possible to identify that the ectopic ureter was found to be intramural. At 2-month follow-up, urinary incontinence had resolved and control ultrasound showed significant improvement in the inflammatory appearance of the right renal parenchyma, with no signs of dilation of the renal pelvis or ureter.Discussion: Different from what happens in male dogs, females with an ectopic ureter will often present with urinary incontinence as the main (and, often, only) symptom, usually in the first months of life. As pollakiuria suggests a wide range of diseases of the urinary tract, ultrasound was considered the first-line imaging modality of choice, indispensable for ruling out other differential diagnoses such as a severe urinary tract infection, urolithiasis, or even malignancy. Despite the literature reporting that urinary incontinence persists in 44 to 67% of cases of ureteral ectopia, even after surgery in this case there was complete recovery of the patient after two months. Accessible techniques like ultrasonography and contrast radiography (excretory urography) supplemented one another in the elucidation of this case, with both demonstrating an excellent contribution to the diagnosis of ectopic ureter as well as served as support for surgical planning, enabling effective repair and consequent recovery of the patient.

Percutaneous closure of ventricular septal defect: Short and medium term results

Ventricular Septal Defect(VSD)is the most common congenital heart disease in children.A minority require closure to avoid complications. Surgical approach is the gold standard.Even if results of surgical closure of VSD are satisfactory, it is associated with complications and inherent risks of sternotomy. Today, Percutaneous Closure(PC)of VSD has become a valuable tool in place of surgery in some cases. This was a retrospective, mono-centric and descriptive study of patients with a VSD in whom a PCVSD was performed. Patients were collected from our Cardiology department over a period from2014 to 2018. Twelve PCVSD were performed. The median age of discovery of VSD was 4 months (2 months to 33 years).The average age of PC was 8 years(2 to 33 years), with a female predominance(8 girls).VSD were perimembranous in 6 cases, and trabecular in the others. The VSD was unique in all cases. The diameter of the VSD was on average 5.7 mm(4 to 13 mm). Left cavities were dilated in 9 patients. Pulmonary artery was dilated in 3 cases. The VSD was restrictive in 11cases.The prosthesis size was(on average 5/5 mm),the largest was 6/6 mm. The type of prosthesis used was ADO II in 11cases,and ADO I in 1case.The 12 VSD were successfully closed. A transient AVB occurred immediately after the closure of a trabecular VSD.A minimal residual shunt was present immediately after closure in 9 cases. After a month all patients were asymptomatic, a residual shunt persisted in 7 cases. SPAP remained stable in all cases and were reduced for the child who initially had PAH. Left cavities remained dilated in the 9patients.1 year after PC, all patients were asymptomatic. A residual shunt was noted in 4 cases. Only 5 patients retained moderate dilation of the left cavities.2patients were put on ACE inhibitor. The follow-up was 2.5 years. PCVSD is a promising alternative to surgery. The results of our study are encouraging despite the small sample size and the absence of a surgical control group

Atrial functional versus ventricular functional mitral regurgitation: Prognostic implications

BackgroundAtrial functional mitral regurgitation (FMR) occurs because of left atrial dilatation or atrial fibrillation in heart failure with preserved left ventricular (LV) function, contrary to ventricular FMR, which occurs because of LV dysfunction. Despite pathophysiological differences, current guidelines do not discriminate between these 2 entities. MethodsFrom January 2002 to March 2019, all adult patients with ≥3+ mitral regurgitation who underwent mitral valve repair or replacement were identified. Postoperative outcomes and midterm time-to-event rates (survival and reoperation) were compared. ResultsOverall, 94 atrial FMR (mean age, 67.6 years) and 84 ventricular FMR (mean age, 64 years) patients met inclusion criteria. Differences in baseline cardiac morphology and function of the atrial FMR and ventricular FMR patients were as follows: concomitant atrial fibrillation (37.2% vs 14.3%), heart failure (42.6% vs 63.1%), LV ejection fraction (60% vs 37%), at least moderate LV dilation (4.8% vs 40.6%), and moderate/severe right heart dysfunction (15.2% vs 5.1%), respectively. Operative mortality was 0% in the atrial FMR versus 1.2% in the ventricular FMR cohort. Actuarial estimates of survival and freedom from reoperation at 5 and 10 years was significantly higher in the atrial FMR cohort versus the ventricular FMR cohort. Ventricular FMR also remained a significant predictor of midterm mortality in our risk-adjusted analysis (adjusted hazard ratio for ventricular FMR, 1.8; 95% confidence interval, 1.001-3.26). ConclusionsThere are important differences in baseline characteristics in terms of cardiac morphology and function among atrial FMR and ventricular FMR patients, which appear to affect in-hospital and midterm outcomes. Because of these discrepancies, early discrimination between these 2 etiologies of FMR might facilitate more tailored approaches to management.

Combination of chronic myocarditis and progressive coronary artery disease: differential diagnosis and stepwise treatment

Aim. To assess the differential diagnosis in a patient with a combination of coronary artery disease and myocarditis and the results of stepwise treatment (including immunosuppressive therapy (IST), and coronary stenting).Material and methods. A 56-year-old female patient with hypertension, obesity (body mass index, 31,6 kg/m2), diabetes and psoriasis developed shortness of breath after a respiratory viral infection. Primary echocardiography revealed left heart dilatation, ejection fraction (EF) of 21%. Coronary angiography revealed anterior descending artery stenosis of 75%, circumflex artery — 80%, right coronary artery (RCA) — 70%. RCA stenting was performed and cardiovascular and diuretic therapy was started. However, shortness of breath and low exercise tolerance persisted.Results. In the blood test, anti-endothelial cell antibodies were 1:320, anticardiomyocyte and anti-smooth muscle antibodies — 1:80, anti-cardiac conduction system fibers — 1:320 (N≤1:40). During myocardial perfusion scintigraphy with computed tomography, an uneven distribution of the indicator was noted. Signs of myocardial scarring and indications for further revascularization were not revealed. Cardiac magnetic resonance imaging confirmed a decrease in left ventricular (LV) contractility (LVEF 37%) and moderate dilatation. Biopsy was not performed due to dual antiplatelet therapy. The condition is regarded as infectious-immune myocarditis. IST was started with azathioprine 150 mg/day. We noted dyspnea relief and a stable increase in LVEF to 50-52%. The clinical course was complicated by sick sinus syndrome with pauses up to 6 seconds and presyncope; a pacemaker was implanted. After 5 years from the onset of IST, dyspnea episodes reappeared without exacerbation of myocarditis. As their cause, ischemia was diagnosed due to the progression of coronary atherosclerosis. Symptoms regressed after repeated coronary stenting.Conclusion. The presence of moderate coronary atherosclerosis without signs of ischemia and myocardial infarction should not be considered as the only cause of severe systolic myocardial dysfunction. Diagnosis and treatment of myocarditis in combination with coronary artery disease is carried out according to the standard principles and can improve LV systolic function and control the heart failure symptoms.

Abstract 16647: Left Ventricular Electro-Mechanical Discoordination is Present in Patients With Tetralogy of Fallot Not Meeting Conventional Criteria for Pulmonary Valve Replacement

Introduction: Pulmonary regurgitation (PR) and RV dilation influence timing of pulmonary valve replacement (PVR) in patients with repaired Tetralogy of Fallot (rTOF). LV function is an independent marker of TOF patient outcomes. New markers of electromechanical discoordination (EMD) have recently been described. Systolic stretch fraction (SSF) quantifies the ratio of ventricular myocardium inappropriately relaxing during systole. Diastolic relaxation fraction (DRF) quantifies inappropriate myocardial contraction during diastole. We analyzed LV EMD using SSF and DRF in rTOF patients with PR who do not meet commonly used criteria for PVR with mild to moderate RV dilation (&lt;150 mL/m 2 ). Hypothesis: Patients with rTOF will have abnormal LV EMD. Methods: Patients (n=18) and healthy controls (n=20) with rTOF and PR underwent cardiac MRI. LV EMD was analyzed using SSF and DRF (Figure) derived from strain and strain rate analysis considering individual LV myocardial segments. Rank-sum test was used to compare groups. SSF and DRF were assessed for linear correlations with RVEDVi by Pearson method. Results: There were 9 male and 9 female TOF patients (Mdn age 15, range 9-55). TOF patients had increased RVEDVi (118±23 ml/m 2 , p&lt;0.001) and increased RVESVi (56±13 ml/m 2 , p&lt;0.001) compared to controls. RV EF was lower in TOF patients but within normal physiologic range (53±6%, p=0.008). LV size indices and EF did not differ. TOF patients had increased SSF (Mdn 0.035, IQR 0.015-0.052, p=0.002) and significantly decreased DRF (Mdn 2.735, IQR 2.358-2.959, p&lt;0.0001). RVEDVi correlated with increased SSF (R=0.51, p=0.011) and decreased DRF (R=0.62, p=0.007). Conclusions: TOF patients with PR and mild to moderate RV dilation have significant LV EMD during both systole and diastole. The degree of systolic and diastolic EMD correlate with RV dilation. SSF and DRF are unique and sensitive early markers of LV dysfunction compared to conventional MRI metrics.

Long-term outcomes amongst adults with anatomic repair for transposition of the great arteries: not as perfect as we would have hoped?

Abstract Background The arterial switch operation (ASO) has replaced atrial switch procedures for D-transposition of the great arteries (D-TGA), with 90% of patients now reaching adulthood. However, patients may have residual lesions and/or sequelae, some of which may remain unrecognized, necessitating lifelong specialist surveillance. We examined the cardiac outcomes of a large number of contemporary ASO patients under tertiary adult congenital heart disease (ACHD) care. Methods We examined late major adverse cardiovascular events (MACE) in adult TGA patients (&amp;gt;16 years) who underwent an ASO between 1981 and 2003 and continued their follow-up in 2 tertiary ACHD centers. MACE were defined as death, re-intervention, myocardial ischemia, arrhythmia, stroke/TIA, infective endocarditis and heart failure. Results Overall, 199 patients (66% male, mean age 27±5 years) were followed in adult life for a median of 10 years [IQR 7–15] and were included in this study. Overall survival during this period was 99.5% (95% confidence interval [CI]: 94.4%-99.8%). Sixty-two (31.2%) patients experience MACE, including 52 reinterventions. MACE and reintervention-free survival at 20, 30 and 35 years were 87.6%, 58.6%, 50.6% and 89.5%, 69.1, 61%, respectively. Atrial arrhythmia was the most frequent cardiac event with an incidence of 5.5 cases per 1000 patient-years, whereas incidence of ventricular tachycardia and sudden cardiac death was 1.8‰ and 0.9‰ patient-years, respectively. Coronary artery disease was diagnosed in 6 (3%) patients, of whom 4 had symptoms, 1 had ST depression on ECG at rest and 3 had abnormal wall motion on echocardiography. The most frequent indication for reoperation was right ventricular outflow tract obstruction (n=35/52, 63.7%), whereas left ventricular outflow tract (LVOT) re-interventions rate increased significantly during adulthood compared to childhood from 1% to 5%, p=0.03 (Figure 1). On multivariate analysis, history of cardiac complications during infancy (HR 2.3, 95% CI:1.3–4.0, p&amp;lt;0.01) and uncommon coronary patterns (HR for type A versus B/C/D/E 0.47, 95% CI:0.26–0.83, p&amp;lt;0.01) were independent predictors of MACE in adulthood. At the latest follow-up, 90.9% of patients were functional class I, left ventricular ejection fraction was 59.6±6.5% and peak oxygen uptake 71.1±24.9% predicted. At least moderate neoaortic regurgitation and aortic dilatation (≥40mm) were present in 8.0% and 35.2%, respectively, with more than mild pulmonary stenosis in 19.6%. Conclusion Adult patients with ASO for TGA have a low late mortality. However, MACE are common requiring reintervention, particularly for RVOT obstruction and neo-aortic valve dysfunction, the latter with rising rates during adulthood. Patients with cardiovascular complications during childhood are at the highest risk for MACE. All patients merit life-long tertiary care. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique des Hôpitaux de Paris

S1529 Occult Portobiliary Fistula Following Percutaneous Liver Biopsy

INTRODUCTION: Percutaneous liver biopsies are commonly performed procedures in the diagnostic workup or staging of liver diseases, and bleeding is the most important complication. Hemobilia is defined as bleeding into the biliary tree, and is a rare complication of liver biopsy that classically presents with a triad of GI bleeding, abdominal pain, and jaundice. CASE DESCRIPTION/METHODS: A 44-year-old male underwent an uneventful liver biopsy for workup of hepatic steatosis. The next day he presented to the ER with RUQ abdominal pain and jaundice. Vital signs were normal and physical examination revealed scleral icterus and epigastric tenderness. Liver function tests showed AST and ALT of 2248 U/L and 2915 U/L, respectively, alkaline phosphatase of 200 U/L, and total bilirubin of 23.3 mg/dL with direct bilirubin of 13.9 mg/dL. CT scan revealed small hemoperitoneum and diffuse hepatic steatosis. Ultrasound with doppler showed normal biliary and intrahepatic ducts and patent portal and hepatic veins with normal blood flow. On the fourth hospital day, MRCP revealed moderate right intrahepatic biliary ductal dilatation with associated hemobilia to the level of the biliary confluence (Figure 1). MRI with contrast revealed completely thrombosed right portal vein and branches, and persistent right intrahepatic biliary ductal dilatation (Figure 2). Oral anticoagulation was considered; however, the gastroenterology team felt the liver biopsy caused an iatrogenic portobiliary fistula, leading to the formation of the portal vein thrombus which may have helped seal the fistula. Therefore, the decision was made to hold anticoagulation and discharge the patient. Liver function tests one month later revealed AST and ALT of 20 U/L and 70 U/L respectively. Repeat MRI showed a reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus with recanalization and mild cavernous transformation (Figure 3). DISCUSSION: Given the biliary dilation on MRCP, we suspect that a blood clot at the biliary confluence caused an obstruction leading to acute severe rise in AST, ALT and direct hyperbilirubinemia. Due to the risk of further bleeding and possible tamponade effect of clot, anticoagulating the patient may have worsened the situation. Portobiliary fistulas leading to hemobilia are a rare complication of percutaneous liver biopsy. While GI bleeding, jaundice, or abdominal pain post-biopsy should prompt a diagnostic workup, it should also be kept in mind that there could be uncommon presentations of hemobilia.Figure 1.: MRCP showing moderate right intrahepatic biliary ductal dilatation with associated hemobilia.Figure 2.: Contrast enhanced MRI showing thrombosed right portal vein and branches, and right intrahepatic biliary ductal dilatation.Figure 3.: Follow-up MRI showing reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus.