Normal Arteries Research Articles

C15. Biventricular Heart Failure and Pulmonary Hypertension in Systemic Sclerosis: a rare and unusual case report

Abstract Backgrounds Systemic sclerosis (SSc), chronic multisystem autoimmune disease, characterized by excessive fibrosis and vascular endothelial dysfunction. Cardiovascular involvement may be induced by various pathways, either primary or secondary to pulmonary hypertension or renal involvement. Case Summary A 46 years old woman presented to emergency department with cold, dark purplish ulcers in fingertips with progressive worsening pain in upper extremities, claudication intermitten, and dyspneu since 4 months ago. She had a mask-like facial, shiny skin, microstomia, restricted mouth opening, calcinosis cutis, Raynauds phenomenon, and sclerodactyly. There were pansystolic murmur grade III/6 in tricuspid area, and rales in basal lungs. ECG showed sinus rhythm with fragmented QRS, poor R-wave progression. Chest X-Ray revealed pancardiomegaly with pleural effusion and HRCT thorax revealed interstitial lungs disease. The laboratory revealed leucocytosis, increase D-dimer (870 ug/L), negative ANA and ds-DNA test, positive anti SCl test. Echocardiography showed biventricular dysfunction with decreased LVEF 37% (Teichz) and TAPSE 10 mm, RA RV dilatation, severe TR with high probability for PH. Extremities Doppler showed normal arteries and veins system. These findings indicates that primary and secondary cardiac involvement in SSc. Heart failure, pulmonary hypertension, and cyclophosphamide medication were administered Discussion Primary cardiac involvement, a direct consequence of SSc, may manifest as fibrosis of the myocardial, conduction system, pericardial and, valvular disease. Furthermore, a secondary phenomenon due to pulmonary arterial hypertension (PAH), and kidney pathology. Though the burden remains low, it may worsen the outcome, consequently, all patients with SSc should undergo screening.

Pulmonary artery diameter: means and normal limits-assessment by computed tomography angiography.

OBJECTIVESNormal pulmonary artery (PA) diameter remains blurred and the definitions of PA aneurysm are heterogenous. We aimed to assess PA diameters, identify a threshold for normal diameters, define PA aneurysms, possible predictors of PA size and evaluate the correlation with mid-ascending aortic diameters.METHODSBetween April 2018 and August 2019, 497 consecutive patients who underwent whole-body computed tomographic angiography were reviewed. Clinical and imaging data were collected from our institutional database. Precise three-dimensional centreline measurements were taken. Linear regression analysis was performed to detect parameters associated with PA diameter. A two-stage model was created to identify potential predictors and the resulting statistically significant interactions were tested. Data were grouped and PA, standard deviation, and upper normal limits were calculated.RESULTSAmong 497 patients with an average age of 51.4 (20.2) (74.6% males), the mean PA diameter measured 32.0 (4.6) mm [female: 31.2 (4.7) mm vs male: 32.2 (4.5) mm; P = 0.032]. The mean PA length, left PA and right PA diameters were similar between male and female patients. We found a significant correlation (r = 0.352; P < 0.001) between the PAs and mid-ascending aortic diameters. Body surface area (P = 0.032, β = 4.52 [0.40; 8.64] 95% CI) was the only significant influencing variable for PA diameter.CONCLUSIONSThe normal mean PA diameter in a reference cohort is 32.0 (4.6) mm. Body surface area is the only influencing variable of PA diameter. The normal diameters measured and corresponding upper limits of normal revealed that a PA aneurysm should not be considered below a threshold of 45 mm.

Longitudinal myocardial function is more compromised in cardiac syndrome X compared to insignificant CAD: Role of stress echocardiography and calcium scoring.

The aim of this study was to assess the nature of myocardial dysfunction in the cardiac syndrome X (CSX) and insignificant coronary artery disease (ICAD) using dobutamine stress echocardiography (DSE) and coronary calcium scoring (CAC). We prospectively studied 35 consecutive patients who complained of exertional angina, had ≥1mm ST shift on exercise stress test but normal or no obstructive CAD (<50%) on angiography. Patients were divided into CSX (n=27) with normal arteries and ICAD (n=8) with insignificant stenosis. CSX patients had more females, lower calcium score and less prevalent cardiac risk factors compared to ICAD (p<0.05 for all). At peak stress, MAPSE and TAPSE failed to increase in both groups. LV septal and lateral s' increased in the two groups but the increment increase was less in CSX than ICAD (p<0.05) while other diastolic indices did not differ between groups (p>0.05 for all). CAC correlated modestly with LV and RV systolic velocities: septal s' (r=-0.65, p<0.001) lateral s' (r=-0.35, p=0.04) and right s' (r=-0.53, p=0.005) in CSX, while in ICAD patients only with RV s' (r=-0.58, p=0.02). On multivariate model, only septal s' OR 1.816 (1.1090-3.820, p=0.04) proved the most powerful independent predictor of CAC. Compromised LV longitudinal systolic velocities were more pronounced and calcium score as a surrogate for atherosclerosis was lower in CSX than ICAD. These findings strengthen the evidence for different pathogenesis of CSX compared to ICAD, with microvascular disease in the former and calcification in the latter.

Numerical Analysis on A Non-Critical Stenosis in Renal Artery

The increase in cardiovascular diseases worldwide has resulted in higher death rate of people globally; the primary reason being atherosclerosis. A better understanding of this condition can be achieved through the application of numerical methods to understand the haemodynamics. The present study aims to investigate the effects of renal artery angulation on the flow characteristics in a non-critically stenosed artery compared to that of a normal artery in order to understand better, the reasons for causes and progression of renal artery stenosis. Abdominal aorta-renal artery models ranging from 30° to 90° angulations were generated from computerized tomography-angiogram slices, post which they were subjected to cleanup and defeaturing. Haemodynamic parameters such as velocity, pressure and time-averaged wall shear stress were evaluated at early systole, peak systole and peak diastole for the different artery models. Extensive amounts of flow recirculation were observed in normal renal arteries with higher bifurcating angles, whereas it was not the case in stenosed arteries where flow acceleration was seen for the duration of the cardiac cycle. Evaluation of static pressure encountered a similar trend where an increase in angulation saw a decrease in pressure for normal arteries which contradicted with stenosed artery results. Analysis of shear stress saw very similar trends in normal and stenosed arteries, with lower angulation profiles experiencing higher values of shear stress at the Ostia. In the cases of arteries of higher angulation with a non-critical stenosis, the possibility of worsening of stenosis into an opprobrious stage remains a concern.

CircRNA Chordc1 protects mice from abdominal aortic aneurysm by contributing to the phenotype and growth of vascular smooth muscle cells

Circular RNAs (circRNAs) have important potential in modulating vascular smooth muscle cell (VSMC) activity, but their roles in abdominal aortic aneurysm (AAA) are unknown. We performed in situ hybridization and immunohistochemistry and determined that circChordc1 (cysteine and histidine-rich domain containing 1) was markedly downregulated in aneurysm tissue compared with normal arteries. A gene gain and loss strategy was used to confirm that circChordc1 transformed VSMCs into a contracted phenotype and improved their growth, which significantly suppressed aneurysm formation and reduced the risk of rupture in mouse models of angiotensin (Ang) II- and CaCl2-induced AAA. RNA pull-down, immunoprecipitation, and immunoblotting indicated that circChordc1 facilitated the VSMC phenotype and growth determination by binding to vimentin and ANXA2 (annexin A2), which not only increased vimentin phosphorylation to promote its degradation but also promoted the interaction between ANXA2 and glycogen synthase kinase 3 beta (GSK3β) to induce the nuclear entry of β-catenin. Thus, our present study revealed that circChordc1 optimized the VSMC phenotype and improved their growth by inducing vimentin degradation and increasing the activity of the GSK3β/β-catenin pathway, thereby extenuating vascular wall remodeling and reversing pathological aneurysm progression.

Numerical simulation of pulsatile blood flow: a study with normal artery, and arteries with single and multiple stenosis

Numerical simulations of pulsatile transitional blood flow through symmetric stenosed arteries with different area reductions were performed to investigate the behavior of the blood. Simulations were carried out through Reynolds averaged Navier-Stokes equations and well-known k-ω model was used to evaluate the numerical simulations to assess the changes in velocity distribution, pressure drop, and wall shear stress in the stenosed artery, artery with single and double stenosis at different area reduction. This study found a significant difference in stated fluid properties among the three types of arteries. The fluid properties showed a peak in an occurrence at the stenosis for both in the artery with single and double stenosis. The magnitudes of stated fluid properties increase with the increase of the area reduction. Findings may enable risk assessment of patients with cardiovascular diseases and can play a significant role to find a solution to such types of diseases.

Analysis of ABC Transporter Gene Expression in Atherosclerosis

ABC transporters are a large family of membrane proteins that transport chemically diverse substrates across the cell membrane. Disruption of transport mechanisms mediated by ABC transporters causes the development of various diseases, including atherosclerosis. Methods: A bioinformatic analysis of a dataset from Gene Expression Omnibus (GEO) was performed. A GEO dataset containing data on gene expression levels in samples of atherosclerotic lesions and control arteries without atherosclerotic lesions from carotid, femoral, and infrapopliteal arteries was used for analysis. To evaluate differentially expressed genes, a bioinformatic analysis was performed in comparison groups using the limma package in R (v. 4.0.2) and the GEO2R and Phantasus tools (v. 1.11.0). Results: The obtained data indicate the differential expression of many ABC transporters belonging to different subfamilies. The differential expressions of ABC transporter genes involved in lipid transport, mechanisms of multidrug resistance, and mechanisms of ion exchange are shown. Differences in the expression of transporters in tissue samples from different arteries are established. Conclusions: The expression of ABC transporter genes demonstrates differences in atherosclerotic samples and normal arteries, which may indicate the involvement of transporters in the pathogenesis of atherosclerosis.

CORRELATION OF ABNORMAL UTERINE ARTERY DOPPLER IN THE SECOND TRIMESTER OF PREGNANCY WITH MATERNAL AND FETAL OUTCOME.

Introduction: Maternal – fetal circulation can be studied non-invasively by using doppler which can be used as a screening tool for fetal and maternal disease. Morphological changes in the uterine vasculature can be demonstrated by colour and pulsed doppler studies. The majority of the studies on uterine artery doppler have focused on a high risk population. The effectiveness of the uterine artery doppler to predict pre eclampsia or FGR in a low risk population has been shown to have a low to moderate predictive value1. Also the criteria for normal and abnormal uterine artery doppler continue to vary with no well accepted denition. Aim: To nd out the correlation between abnormal uterine artery doppler in the second trimester of pregnancy between 18-22 weeks, with the subsequent development of pre eclampsia and FGR. Materials and methods: This is a prospective cohort study carried out in the Department of Obstetrics and Gynecology for a period of one year. Antenatal patients in the age group of 18-35 years, between 18-22 weeks of gestation, who were included in the study underwent a uterine artery doppler. They were followed up until delivery. SPSS software was used to analyze the data. Results: 193 Obstetric patients in the age group 18-35 years were evaluated with uterine artery doppler. 77.7% had normal doppler indices. In the abnormal doppler group, 81.4% were in the high risk category and 48.8% of those with abnormal dopplers developed pre eclampsia and 34.9% with abnormal dopplers developed FGR. Conclusion: Patients with abnormal uterine artery doppler indices in the second trimester of pregnancy, had an 18 times increased risk of developing pre eclampsia and a 6 times increased risk of developing FGR when compared to those with normal doppler indices.

Anomalous Anatomical Variations of Coeliac Trunk: A Cadaveric Study.

BackgroundThe celiac trunk, celiac axis or celiac artery is the first major abdominal branch of the aorta. Anatomical variations of the coeliac trunk and along with the other branches of the abdominal aorta result from changes in the ventral segmental arteries supplying the digestive tube during foetal development. Panagouli performed a systemaic review and proposed a new classification describing all celiac trunk variations through a systematic review. Knowledge of the celiac trunk anatomy and any variations is clinically relevant in esophageal, gastroduodenal, hepatic, biliary and pancreatic angiographic and surgical procedures. The purpose of this study is to report the pattern of the celiac trunk and its variations in a sample of the Indian population as per the Panagouli classification.MethodsThis was an observational study done in the period from September 2018 to October 2020 in the department of surgery of Gandhi Medical College & Hamidia Hospital, Bhopal, India. Cadaveric dissection was carried out in the department of forensic medicine and toxicology after obtaining approval from the ethical committee.ResultsWe did our study in 50 cadavers to look for further anatomical variations. The most common form found was true tripus Halleri. The rest of the variations noted included false tripus Halleri. Other variations were hepatosplenic trunk with left gastric artery arising from the aorta (6%), hepatosplenic trunk with no normal left gastric artery (2%), Hepatosplenic trunk with gastromesenteric trunk (2%) and coeliacomesenteric trunk (2%).ConclusionsThe congenital anomalies of the coeliac trunk have been long recognized and are of significant clinical importance as they may surprise the surgeon during surgery. Also, the wide spectrum of anomalies present in this area can be recognized by modern radiological evaluations like multi-detector helical computed tomography, MRI and magnetic resonance cholangiopancreatography (MRCP). Having the knowledge of these anatomical variations in mind may prevent inadvertent injuries during routine and complex hepato-pancreaticobiliary procedures.

Comparative study of umbilical cord cross-sectional area in foetuses with isolated single umbilical artery and normal umbilical artery

Single umbilical artery (SUA) is one of the most common prenatal diagnoses in cases of foetal abnormality. This prospective study evaluated 77 foetuses with isolated SUAs and 77 healthy foetuses, both at 22–39 gestational weeks. We categorised gestational age into the second and third trimesters, measured the umbilical arterial blood flow parameters and calculated the umbilical vein (UV) area, umbilical artery (UA) area and UV area/UA area ratio. In the second and third trimesters, a higher UA area was obtained in the isolated SUA group than in the control group (p < .01). Furthermore, the isolated SUA group had a lower UV area/UA area ratio than the control group (p < .01), and a positive linear correlation was found between gestational age and UV area in both groups (p < .01). The presence of isolated SUAs was associated with low birth weight and a high prevalence of small for gestational age. IMPACT STATEMENT What is already known on this subject? Single umbilical artery (SUA) is one of the most common prenatally diagnosed foetal abnormalities and approximately 80% foetuses with SUA have isolated SUA, which is a soft indicator of chromosome abnormalities, congenital malformations and premature birth. Umbilical cord cross-sectional area can be evaluated prenatally by ultrasound imaging. Normal values increase with gestational age and foetal size in single pregnancies. Changes in umbilical cord thickness have been associated with complications during pregnancy. What do the results of this study add? The correlation between gestational age and umbilical vein area in the isolated single umbilical artery (SUA) group and control group was better than that between gestational age and umbilical artery area. UA area increased significantly in both groups before 28 weeks but not after 28 weeks, particularly in the isolated SUA group. What are the implications of these findings for clinical practice and/or further research? The study provides a reliable basis for maternal foetal monitoring during pregnancy in the isolated SUA and control groups. Objective assessment of the occurrence and development of foetuses with isolated single umbilical artery was performed.

Bridging Coronary Physiology into Clinical Application of Acute Coronary Syndrome

Normal arteries have three layers of structure, tunica intima, tunica media, and tunica adventitia. Intima tunica is the deepest layer of coronary arteries in which there are antithrombotic molecules such as heparin sulfate, thrombomodulin, and plasminogen activator. In addition, tunica intima also contains substances that regulate the contraction of tunica smooth muscle cell media, called nitric oxide (vasodilators) and prostacyclin (vasoconstrictors). Tunica intima and tunica media seem to be directly related to the atherosclerosis process. Meanwhile, the role of tunika adventisia is unknown. The accumulation of atherosclerotic lesions and hemodynamic stress factors and the degradation of extracellular matrix will cause susceptibility of atherosclerotic plaque fibrous capsules to rupture and form thrombus. Thrombus that occurs in the coronary condition causes acute coronary syndrome, characterized by typical symptoms such as chest pain depending on the thrombus formed. In studying acute coronary syndromes, of course it cannot be separated from understanding the physiology of coronary arteries and the process of atherosclerosis. Therefore, this article aims to briefly explain coronary physiology.

Adverse perinatal outcomes in fetuses with severe late-onset fetal growth restriction

Objective To evaluate perinatal outcomes in fetuses with severe late-onset fetal growth restriction. Methods This was a retrospective and observational cohort study in which pregnant women diagnosed with late-onset fetal growth restriction assisted at perinatal maternity birth from 2010 to 2017 were included. The outcomes were intensive care unit (ICU) admission and perinatal complications, such as neonatal death, intraventricular hemorrhage, periventricular leukomalacia, hypoxic-ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, and sepsis. Results We selected 277 pregnant women, of whom 124 newborns (44.76%) went to the ICU. The chance of a newborn needing ICU decreases by 62, 7, and 9% according to an increase of one gestational week, 1 cm of the abdominal circumference, or 1 cm of the amniotic fluid index, respectively. Oligohydramnios increases the risk of going to the ICU by 2.13 times. The increase in the umbilical artery pulsatility index (PI) Doppler increases the chance of ICU admission by 7.9 times. The normal middle cerebral artery PI Doppler and the normal cerebroplacental ratio reduce the risk of ICU admission. Conclusion The estimated fetal weight, abdominal circumference, and amniotic fluid index diagnosed severe late-onset fetal growth restriction. With the decrease in middle cerebral artery PI Doppler, there is a greater probability of admission to the ICU, with the most common complications being intraventricular hemorrhage and necrotizing enterocolitis.

Moving shear stress towards the clinic: preclinical comparison of optical coherence tomography-based versus angiography-based time-averaged wall shear stress estimations

Abstract Introduction Identification of coronary atherosclerotic plaques at risk of causing future acute coronary syndromes remains a major unmet clinical challenge. The addition of vessel biomechanics to intracoronary imaging derived evaluation of plaque morphology, improves identification of plaques likely to develop high risk features. We and others have developed a framework for intracoronary imaging (optical coherence tomography [OCT]) based 3D reconstructions of coronary arteries for computational fluid dynamics (CFD) simulations of shear stress, which are considered the current gold standard approach for quantification of coronary arterial haemodynamics. However, these approaches are time consuming and computationally intensive, resulting in a barrier to clinical uptake. Purpose Determination of time averaged wall shear stress (TAWSS) based on 3D coronary geometries from non-invasive 3D Quantitative Coronary Angiography (3D-QCA) has recently been developed (Pie Medical Imaging, Netherlands), which enables results of shear stress simulations to be available within 30 minutes. We sought to compare TAWSS determined from 3D-QCA with gold standard OCT-based CFD simulations in both normal and stenotic arteries in minipigs. Methods 15 normal and 5 stenotic minipig coronary arteries were studied. Anatomically matched 3D arterial geometries were reconstructed from 3D-QCA and OCT using common centrelines. Boundary conditions for simulations included directly measured inlet blood velocities; parabolic inlet flow profiles, zero pressure outlet; no-slip arterial walls; blood density: 1.05 g/ml; blood dynamic viscosity: 0.035 g/cm.s. Blood was modelled as Newtonian. 3D-QCA TAWSS was obtained with a Kratos Multi-Physics CFD solver. OCT-based simulations were performed using Abaqus/CFD v6.14. TAWSS was calculated for 80 axially matched segments for both methods (1200 and 400 paired comparisons for normal and stenotic arteries, respectively). Data were analysed using Bland-Altman and Wilcoxon matched-pairs signed ranked tests. Results Computation times for 3D-QCA and OCT-based CFD were approximately 30 minutes and 2 hours respectively. Axial profiles of TAWSS were similar between the two methods and there was agreement in TAWSS magnitudes and narrow 95% limits of agreement (Figure 1 and Figure 2). Using co-registered TAWSS maps generated by each method, we find similar spatial regional distributions of TAWSS in both normal and stenotic arteries. Conclusions Our data suggest that 3D-QCA based TAWSS is feasible in both normal and stenotic arteries. Spatial TAWSS distributions between the two methods are similar with agreement in matched TAWSS comparisons, though there are some small systematic differences in the absolute values of TAWSS, due to different resultant arterial geometries. These encouraging data suggest that further clinical evaluation of rapid TAWSS from 3D-QCA is warranted, which may facilitate clinical adoption of TAWSS assessment. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Medical Research Council

A modified Dabestani-Mahan formula estimates a normal pulmonary artery systolic pressure: a single-center retrospective study

Abstract Background Pulmonary artery systolic pressure (PASP) is increasingly used as an important datapoint in clinical decision-making and prognostication even in specialties outside of cardiology. Estimation of PASP by Doppler quantification using tricuspid regurgitation (TR) peak velocity is commonly used and correlates well with invasive measurement by right heart catheterization. Further study of transthoracic echocardiogram (TTE) techniques to estimate PASP is needed to provide this datapoint in the absence of sufficient Doppler data for the TR peak velocity method. One technique using right ventricular outflow tract acceleration time (AT) to estimate mean pulmonary artery pressure (MPAP) has been proposed by Dabestani Et al. by the equation MPAP=90-(0.62x AT). Assuming a linear relationship between MPAP and PASP, as suggested by Chemla Et al. by MPAP=(0.61xPASP)+2, a modified formula PASP=145-AT could possibly estimate a normal PASP ≤25 mmHg. Purpose To examine if a modified Dabestani-Mahan formula PASP=145-AT can estimate a normal PASP ≤25 mmHg as calculated by the TR peak velocity method. Methods We queried the electronic medical record at our institution for a sample of 300 patients who had a TTE performed between 2017 and 2020. Each TTE was reviewed and PASP was estimated for each using the TR peak velocity method. A right atrial pressure of 3 mmHg, 8 mmHg, or 15 mmHg was used in the estimation based on inferior vena cava diameter and collapsibility in keeping with the 2015 American Society of Echocardiography guidelines. A short axis view of pulmonary flow using the pulse-waved Doppler sample volume over the transpulmonary valve jet was then reviewed. The time from onset of ejection to peak flow velocity was measured manually as AT in milliseconds using Change Healthcare Cardiology Web Software Package 14.1.1. The measured AT was averaged over three cardiac cycles. Patients with a heart rate between 60 and 100 beats per minute at time of TTE and with sufficient Doppler data to estimate PASP by TR peak velocity and to measure AT were included in a logistic regression analysis. Results 154 patients were included in the statistical analysis. Patients who had a right ventricular outflow tract acceleration time greater than 120 milliseconds, giving a PASP ≤25 mmHg by the modified formula PASP=145-AT, had a 36 times greater odds of having a PASP ≤25 mmHg by the TR peak velocity method (OR=36.0, 95% CI=10.36–125.12, p&amp;lt;0.001). Conclusion(s) Based on a single-center sample, a right ventricular outflow tract acceleration time greater than 120 milliseconds could be used to estimate a normal pulmonary artery systolic pressure less than or equal to 25 mmHg in the absence of sufficient Doppler data for the commonly used TR peak velocity method. Funding Acknowledgement Type of funding sources: None.

The right ventricular-pulmonary circulation coupling in ischaemic heart disease; a stress echocardiography study

Abstract Objectives This study sought to assess the right ventricular (RV) - pulmonary circulation coupling in patients with coronary artery disease (CAD), preserved echocardiographic indices of right ventricular systolic function and normal pulmonary artery systolic pressure (PASP). Background Patients with CAD are at increased risk for developing left, and ultimately right heart failure. The analysis of underlying mechanisms of worsening RV function has been limited to the hemodynamic sequelae of increased left ventricular (LV) filing pressure leading to pulmonary hypertension. It has been reported that evaluation of RV functional state by using the tricuspid annular plane systolic excursion (TAPSE)/PASP ratio as a surrogate for the RV length-force is of clinical prognostic relevance in patients with known pulmonary hypertension; its role has not been extensively explored in other cardiac conditions including myocardial ischaemia. We hypothesized that the TAPSE/PASP ratio may be able to identify early and subtle changes in RV function in patients with CAD, normal estimated resting PASP, and preserved TAPSE. Methods Data were obtained from a prospectively maintained database, and 223 consecutive patients with preserved right ventricular systolic function (TAPSE≥16mm), and normal resting PASP (≤35mmHg), undergoing stress echocardiography (SE) for suspected coronary artery disease were included. Exclusion criteria: non-ischaemia study, severe valvular disease, poor image quality, resting pulmonary hypertension, reduced right ventricular systolic function. Transthoracic 2-D Doppler echocardiogram was performed by an accredited sonographer at rest and during stress phase and reviewed by two cardiologists unaware of clinical data. Results Fifty-three (24%) SE studies were positive for ischaemia and 170 (76%) negative. Demographic characteristics of both groups are shown in Table 1. All patients had TAPSE≥16mm and a PASP≤35mmHg as per inclusion criteria. The mean TAPSE/PASP ratio was significantly lower in patients with a positive SE suggestive of CAD than controls (0.84±0.22 vs 0.93±0.24, P=0.024). The TAPSE/PASP ratio showed significant correlation with the maximum workload (Watts) achieved (r=0.17, P=0.015) and exercise time (min) (r=0.15, P=0.031), and an inverse correlation with age (r=−0.26, P&amp;lt;0.001) and the development of inducible exertional breathlessness (Exp(B) 0.11, 95% CI 0.028–0.457, P=0.002) on SE. Conclusion Resting TAPSE/PASP was reduced in patients with positive SE, compared to controls. Indexing RV function to RV load, with the use of the TAPSE/PASP ratio identified early changes in RV-pulmonary circulation coupling in CAD patients without resting pulmonary hypertension; this may denote the beginning of subclinical RV dysfunction. Funding Acknowledgement Type of funding sources: None. Table 1

Pediatric Popliteal Artery Pseudo-Aneurysm: A Case Report and Literature Review

<h3>Introduction/Objectives</h3> Osteochondroma is the most common benign, skeletal tumor occurring in 1% of the population and is most prevalent in males.¹ Rarely, they can be associated with vascular complications, in the lower extremity most commonly affecting the popliteal artery.² We describe a case of a young male who presented with right knee pain and a history significant forprevious removal of bilateral tibial osteochondromas that were symptomatic. He was found to have a large popliteal pseudo-aneurysm associated with a posterior right distal femur osteochondroma. <h3>Case Report</h3> A 16-year-old male with a past medical history of multiple hereditary exostoses was seenas an outpatient due to sudden right knee pain and tightness over his popliteal fossa that started occurring over the last several days. Three years prior he underwent removal of bilateral medial proximal tibial osteochondromas that were symptomatic. He was found to have a large popliteal pseudo-aneurysm on CT measuring 3.5 × 5.6 × 6.6cm with thrombus visualized with the aneurysm (Fig. 1Figure 1CT image demonstrating a large popliteal artery pseudo-aneurysm in association with an osteochondroma spike. Orlando Health, Department of General Surgery, Orlando, FloridaFigure 1). An arterial duplex was also obtained (Fig. 2Figure 2Proximal, mid, and distal representations of popliteal pseudo-aneurysm on arterialduplex. Orlando Health, Department of General Surgery, Orlando, FloridaFigure 2). There was no evidence of neurological compromise and distal pulses were palpable. In the operating room, the right thigh greater saphenous vein was harvested endoscopically with the patient in the supine position. Concerned about our ability to obtain proximal control from the prone position, our attention was turned to the above-knee popliteal fossa and proximal control of the popliteal artery was obtained. The patient was then placed in the prone position. We created a "Lazy S" incision and deepened the incision over the popliteal fossa. We dissected over the large pseudo-aneurysm, continuing our dissection distally until normal popliteal artery was encountered, obtaining distal control. Although the pseudo-aneurysmextended approximately 20cm, the diseased portion of the artery was only approximately 0.5cm (Fig. 3Figure 30.5cm segment of diseased portion of popliteal artery, anterior surface (left) andposterior surface (right). Video link below.Figure 3). We were able to separate the underlying pseudo-aneurysm from the normalized artery and again ensured proximal and distal control. We entered the sac and encountered a large amount of clot, this was evacuated (Fig. 4Figure 4Clot evacuated from pseudo-aneurysm sac.Figure 4). We then began to resect the pseudo-aneurysm wall distally, this allowed us to encounter the spike coming off of the osteochondroma which was essentially a sharp, pointed segment (Fig. 5Figure 5Osteochondroma spike.Figure 5). At this point the orthopedist took over resecting thissegment, we then resected the diseased portion of the artery and performed our repair of the popliteal artery with reversed greater saphenous vein in an end-end fashion (Fig. 6Figure 6Repair of popliteal artery with greater saphenous vein.Figure 6). The patient was discharged the following day with strongly palpable pulses and no in-hospital complications. Unfortunately, the patient was lost to follow up. <h3>Discussion</h3> Osteochondromas develop from skeletal elements that have undergone endochondral ossification and can occur at any time of the human skeletal growth phase. They are ‘protected' by a soft hyaline cartilaginous cap that is identical to the epiphyseal plate and undergoes ossification following cessation of growth.³ They are often solitary (90% of cases) although when multiple represent a hereditary autosomal dominant condition as in our patient's case. Thepopliteal artery is particularly susceptible to pseudo-aneurysmal changes as it is fixed between Hunter's canal superiorly and popliteus muscle inferiorly, preventing displacement from any underlying lesion. There have been multiple studies suggesting that following the cessation of growth, the cartilaginous cap undergoes ossification resulting in a sharp bone spur. As the vesselbecomes tethered, the resulting constant compression and pulsatile friction against the ‘non- protected' osteochondroma causes continuous injury to the vessel wall, resulting in pseudo- aneurysm formation.^4-6 Early surgical repair is mandatory, conservative management has been shown to increasethe risk of secondary complications including venous thrombosis, and distal emboli.^7-9 Posterior and medial surgical approaches have both been described, venous patch angioplasty, vein/prosthetic bypass and ligation. We adopted a posterior approach to the lesion, utilizing a greater saphenous vein bypass. <h3>Conclusion</h3> Popliteal pseudo-aneurysms are the most common vascular sequela of femur osteochondromas due to the superior and inferior fixation of the vessel. Post-operative imaging investigations should be considered due to multiple osteochondromas occurring in about 10% ofpatients as evidenced in our case.

Transcatheter aortic valve replacement using the iSleeve expandable sheath in small femoral arteries

BackgroundSmall femoral arteries have been associated with a higher risk of vascular complications in transfemoral transcatheter aortic valve replacement (TAVR). We investigated the feasibility and safety of TAVR in patients...

Cervical Aortic Arch with Hypoplastic Left Common Carotid Artery and Subaortic Left Brachiocephalic Vein.

Cervical Aortic Arch with Hypoplastic Left Common Carotid Artery and Subaortic Left Brachiocephalic Vein.

Preeclampsia Falling into the Spectrum of Mirror Syndrome

Mirror syndrome, by definition, is maternal edema with fetal hydrops. Majority of the pregnancies in developing countries are complicated by preeclampsia and intrauterine growth retardation. Fetal ascites, on the other hand, is a part of spectrum of the condition under hydrops fetalis. Abnormal umbilical artery Doppler is an indicator of fetal growth retardation and not many cases are found with such diversely intermixed conditions. A 26-year-old primigravida with 36 weeks gestation by the last menstrual cycle and 34 weeks by ultrasound presented to our hospital with a history of decreased fetal movements, headache, fever, weakness, dizziness, and new-onset raised blood pressure. Her blood pressure was 164/118 and 3+ proteinuria on the urinary dipstick test. A diagnosis of preeclampsia was made. An antenatal ultrasound was performed, which showed fetal ascites, mild thickening of fetal skin, oligohydramnios with reversed umbilical artery flow but normal uterine arteries, and middle cerebral arteries. The blood pressure was controlled and she later delivered a low-birth weight baby that needed neonatal intensive care unit stay for fetal distress and abdominal distention. The baby did not survive the coming few days and died due to increasing fluid in the body cavity. The mother continued to have raised blood pressure in the postpartum period. Mirror syndrome is when the maternal pathology mirrors that of the fetus. Preeclampsia, fetal hydrops, and placental edema are the conditions lead to suspicion of it. In the case, we present, the mother had preeclampsia, and there was fetal ascites and reversed umbilical flow. The fetal and maternal outcome was in the form of intrauterine growth retardation, impending hydrops fetalis and chronic hypertension, respectively.

Percutaneous treatment of anomalous systemic artery to pulmonary venous fistulas in children

In the normal lung, the only communications between the systemic and pulmonary arterial systems are the connections between the bronchial and pulmonary arteries that occur at the respiratory bronchioles, where pulmonary and bronchial capillaries freely anastomose. Rarely, anomalous connections can occur between normal or aberrant systemic arteries and pulmonary vessels. We performed a comprehensive literature review of all available manuscripts on PubMed and Google Scholar that included a case report or case series with diagnosis of systemic artery to pulmonary venous fistulas who underwent percutaneous treatment. Furthermore, we report three cases of children diagnosed and treated in our Pediatric Cardiology Center.