Peak Systolic Pressure Gradient Research Articles

Surgically induced aortic coarctation in a neonatal porcine model allows for longitudinal assessment of cardiovascular changes.

Noncritical aortic coarctation (COA) typically presents beyond early childhood with hypertension. Correction of COA does not ensure a return to normal cardiovascular health, but the mechanisms are poorly understood. Therefore, we developed a porcine COA model to study the secondary cardiovascular changes. Eight male neonatal piglets (4 sham, 4 COA) underwent left posterolateral thoracotomy with descending aorta (DAO) mobilization. COA was created via a 1-cm longitudinal DAO incision with suture closure, plication, and placement and an 8-mm external band. All animals had cardiac catheterization at 6 (11-13 kg), 12 (26-31 kg), and 20 (67-70 kg) wk of age. Aortic luminal diameters were similar along the thoracic aorta, except for the COA region [6.4 mm COA vs. 17.3 mm sham at 20 wk (P < 0.001)]. Collateral flow could be seen as early as 6 wk. COA peak systolic pressure gradient was 20 mmHg at 6 wk and persisted through 20 wk increasing to 40 mmHg with dobutamine. Pulse pressures distal to the COA were diminished at 12 and 20 wk. This model addresses many limitations of prior COA models including neonatal creation at an expected anatomic position with intimal injury and vessel sizes similar to humans.NEW & NOTEWORTHY A neonatal model of aortic coarctation was developed in a porcine model using a readily reproducible method of aortic plication and external wrap placement. This model addresses the limitations of existing models including neonatal stenosis creation, appropriate anatomic location of the stenosis, and intimal injury creation and mimics human somatic growth. Pigs met American Heart Association (AHA) criteria for consideration of intervention, and the stenoses were graded as moderate to severe.

Long-term outcomes of surgical or endovascular treatment of adult with midaortic syndrome: A single-center retrospective study over a 14-year period

ObjectiveMidaortic syndrome is a rare clinical condition that has been mainly studied in juveniles through case reports and series. This study aims to report the anatomic characteristics and long-term outcomes of 41 adult patients with midaortic syndrome who received open surgical treatment or endovascular treatment over a 14-year period. MethodsA consecutive cohort of 41 adult patients diagnosed with midaortic syndrome at our center between January 2008 and November 2021 were enrolled in the study. Patients’ baseline and anatomic characteristics were collected and analyzed. Primary follow-up outcomes included death and reintervention. Other follow-up outcomes included hypertension and complications. ResultsThe study enrolled 41 adult patients with midaortic syndrome with a mean age of 37.5 ± 13.4 years. Twenty-five patients received open surgical treatment, and 16 patients received endovascular treatment. Isolated infrarenal lesions were more likely to be found in the endovascular treatment group (P = .005), whereas patients with multiple (P = .002) or intravisceral involvement (P = .001) were more likely to be found in the open surgical treatment group. The open surgical treatment group was more likely to have a lower postoperative peak systolic pressure gradient (P = .020). The 5- and 10-year reintervention-free survivals were 87.7% and 71.7% in the open surgical treatment group and 92.3% and 79.1% in the endovascular treatment group, respectively. ConclusionsBoth open surgical treatment and endovascular treatment showed satisfactory long-term efficacy outcomes for adult patients with midaortic syndrome. Given the patients’ relatively young age and long life expectancy, strict and regular lifelong follow-up is necessary.

Pictorial rendition of author’s observations on balloon valvuloplasty/angioplasty procedures: Pulmonary stenosis

Balloon valvuloplasty/angioplasty techniques have been available to address valvar and vascular obstructions associated with congenital heart defects (CHDs) since the 1980s. The objective of this paper is to provide a pictorial rendition of the author&amp;rsquo;s observations over the last four decades on these techniques. In this paper, balloon pulmonary valvuloplasty (BPV) for treating isolated pulmonary stenosis (PS), PS associated with cyanotic CHDs, and bioprosthetic valve in the pulmonary position were reviewed. Balloon dilatation leads to a decrease in the peak systolic pressure gradient through the pulmonary valve during BPV, as well as at intermediate-term and long-term evaluation. Problems, such as the reappearance of obstruction at intermediate-term follow-up and pulmonary insufficiency (PI) at long-term follow-up, have been documented in isolated PS cases but are infrequent. Repeat balloon valvuloplasty for restenosis has been successfully used. The development of infundibular obstruction in PS cases was also reviewed. To decrease the frequency and degree of PI, the author has revised the recommendations for balloon/annulus ratios used for BPV from the previous 1.2 &amp;ndash; 1.4 to 1.2 &amp;ndash; 1.25. In patients with PS associated with cyanotic CHD, improvement of oxygen saturations at the time of BPV and enhanced anatomy during follow-up were observed. BPV of bioprosthetic valves results in minimal improvement in the pulmonary valve gradient, and stents may be a better alternative to address this problem.

Clinical and Paraclinical Findings of Primary Pulmonary Hypertension in Children

Background: Given the significant morbidity and mortality of juvenile pulmonary arterial hypertension (PAH), understanding the clinical and paraclinical findings of this condition can aid in the early diagnosis and identification of helpful factors in its treatment. Objectives: This study aimed to evaluate the clinical and paraclinical findings of idiopathic pulmonary arterial hypertension (iPAH) in children. Methods: This cross-sectional study was carried out on 20 children with iPAH who were assessed in terms of pulmonary hypertension or hospitalized at the cardiac ward of Imam Reza hospital, Mashhad, Iran, during January 2018 to October 2001. The clinical data, chest X-ray (CXR), electrocardiographic, echocardiographic, cardiac catheterization findings, and mortality results were extracted from the medical records and recorded in a researcher-made questionnaire. Results: The current study’s findings revealed a higher prevalence of iPAH in females (70%) than men, as well as in term neonates compared to preterm newborns. The most common clinical findings were active dyspnea, heart murmur, and cyanosis. Prominent pulmonary conus, right atrial enlargement (RAE), and right ventricular hypertrophy (RVH) were the most common CXR findings. The right axis deviation, RVH, and RAE were the most common abnormal findings of electrocardiography, respectively. Based on echocardiographic findings, dilated right atrium and dilated right ventricle were reported in all subjects. The mean of tricuspid regurgitation pressure gradient (TRPG) and peak systolic pressure gradient (PSPG) were 76.33 ± 22.8 and 44.2 ± 13.18 mmHg, respectively. The mean ratios of systolic pulmonary artery pressure (PAP), diastolic PAP, and mean pulmonary artery pressure (mPAP) to aortic systolic pressure were estimated at 0.92, 0.78, and 0.88, respectively. The results confirmed a significant relationship between mPAP and consanguinity (P = 0.03). In addition, the findings demonstrated a correlation between echocardiographic findings (i.e., TRPG and PSPG) and systolic PAP, diastolic PAP, and mPAP (P &lt; 0.05). In total, 56.3% of the patients expired, most of whom (37.5%) were the younger children. Conclusions: The findings suggest that IPAH should be considered as a possible diagnosis in various clinical manifestations, including respiratory distress, hepatomegaly, ascites and even neurological symptoms. Since there are no specific symptoms, therefore a set of history, physical examination, laboratory findings, and clinical suspicion should be taken into consideration.

Effects of oral propranolol on the resistive and pulsatility indices of major abdominal vasculatures in domestic short-haired cats.

No study has been performed regarding the effects of oral administration of propranolol on pulse-wave spectral Doppler indices of major abdominal vessels in healthy adult cats. The objective of this study was to assess the pulse-wave spectral Doppler indices of abdominal aorta, caudal vena cava, and portal vein in clinically normal adult domestic short-haired (DSH) cats, before and after propranolol ingestion. Twenty intact adult client-owned DSH cats were evaluated (10 males and 10 females). A duplex Doppler ultrasonography machine with a 10-MHz frequency linear transducer was used. Peak systolic velocity, end-diastolic velocity (EDV), resistive index (RI), pulsatility index (PI), and pressure gradient were measured. All the cats received 1mg/kg of propranolol tablet, and after 2 h, ultrasonography measurements were repeated. The mean RI of the aorta and caudal vena cava significantly decreased in male cats following oral administration of propranolol after 2 h (p = 0.03, p = 0.02). In the caudal vena cava, the PI decreased from 2.98±0.62 to 1.15±0.19 post-propranolol ingestion (p = 0.01). The mean EDV in the caudal vena cava of males and portal veins of females significantly decreased after propranolol ingestion (p = 0.04, p = 0.02). This study showed that propranolol decreased the PI of the aorta and PI and RI of the caudal vena cava in healthy normal cats 2 h post-propranolol ingestion at the dosage of 1mg/kg.

Aortic Coarctation Stenting in Adolescents and Adults: A Single-Center Experience.

The aim of this study was to evaluate the short and midterm results of aortic coarctation (AoCo) stenting in an adolescent and adult population. All patients with a AoCo older than 14years treated by stent placement between December 2000 and November 2016 were included in this study. Twenty-eight patients with an invasive peak systolic pressure gradient >20mmHg were identified. Number of redilations, non-invasive systolic blood pressure, peak systolic pressure gradient, antihypertensive medication intake, claudication status and complications were evaluated. Twenty-two covered and 6 uncovered stents were successfully placed. Peak systolic pressure gradient decreased immediately after stenting from a mean of 32 mmHg to 0mmHg (± 7mmHg). Mean AoCo diameter increased from 8 tot 16mm (± 4mm). Peripheral arterial injury was seen in 2 patients (7.1%). The mean follow-up time was 60 ± 49months. Redilation of the stent was required in 4 patients, 2 to accommodate for growth and 2 for restenosis. Six (35%) patients could stop all antihypertensive medication. All claudicants (6/28) became and remained asymptomatic after surgery and during their follow-up. No aneurysms, stent fractures or dissections were noticed. There were 2 stent migrations during the first procedure with only 1 needing additional stent placement. Aortic coarctation stenting is a safe and effective treatment that significantly reduces the peak systolic pressure gradient. Antihypertensive medication can be reduced, and increase of walking distance in claudicants can be obtained. Younger patients may need more frequent reinterventions to accommodate for growth.

Red blood cell abnormalities occur in dogs with congenital ventricular outflow tract obstruction.

To document RBC abnormalities in dogs with congenital ventricular outflow tract obstruction. 62 dogs with pulmonic stenosis (PS) or aortic stenosis (AS) and 20 control dogs were recruited. The proportions of RBCs that were schistocytes, acanthocytes, and keratocytes were assessed. Complete blood cell counts were performed. Tested variables included hemoglobin concentration, hematocrit, and erythrocyte count. Median (interquartile range [IQR]) peak systolic Doppler-derived trans-stenotic pressure gradient (∆P) values were 161 mm Hg (108 to 215 mm Hg) and 134 mm Hg (125 to 165 mm Hg) for dogs with PS and AS, respectively. Hematologic abnormalities were detected in most dogs with AS or PS (54/62 [87%]) versus 8/20 [40%] in control dogs, with schistocytes found in 40 of 62 (65%; median, 0.1% RBCs; IQR, 0% to 0.3%), acanthocytes in 29 of 62 (47%; median, 0.3% RBCs; IQR, 0% to 0.9%), keratocytes in 39 of 62 (63%; median, 0% RBCs; IQR, 0% to 0.2%), and hemolytic anemia in 4 dogs with PS. No significant association was identified between these abnormalities and ∆P. However, 3 of 4 dogs with anemia had a ∆P > 200 mm Hg (range, 242 to 340 mm Hg). The dog with the highest ∆P value also had the most severe anemia and schistocytosis, and both resolved after balloon valvuloplasty. Poikilocytosis is common in dogs with congenital ventricular outflow tract obstruction, with anemia only observed in few dogs with high ∆P values.

Septal myectomy with mitral valve surgery in patients after alcohol septal ablation.

OBJECTIVESWe studied 16 patients after failed alcohol septal ablation who underwent extended septal myectomy to analyse the results of surgical correction and identify technical pitfalls the surgeons may be confronted by.METHODSBetween October 2017 and March 2019, 16 patients underwent surgical extended septal myectomy with accompanying anomalous secondary chordae resection, papillary muscles mobilization [in 9 (56.3%) patients], and anterior mitral leaflet plication after previously failed alcohol septal ablation. Routine preoperative computed tomography or cardiac magnetic resonance planning and intraoperative transoesophageal echocardiography were performed in each of the studied patients. Major technical features were identified and complemented during septal myectomy of the calcified interventricular septum.RESULTSThe mean age of the studied patients accounted 50.5 ± 14.6, median—54; males—5 (31.3%). Mean cross-clamp time accounted 52 ± 7.2 min. Calcified basal interventricular septum was identified in 2 (12.5%) patients. No iatrogenic ventricular septal defect (0%) was made during surgical correction. Peak systolic pressure gradient decreased from 86 (interquartile range: 75–104.7) to 20 (16–22) mmHg (P< 0.001). No patients with moderate or severe mitral regurgitation were identified, whereas before the procedure, the number of those accounted 13 (81.2%) individuals. In-hospital and overall mortality after septal myectomy accounted 0%.CONCLUSIONSExtended septal myectomy in patients who previously underwent alcohol septal ablation is a safe procedure that affects all pathological manifestations of the disease. Routine preoperative computed tomography or cardiac magnetic resonance provides detailed anatomy of the anomalous left ventricle and subvalvular structures and allows to measure the extension of myectomy preventing the occurrence of iatrogenic ventricular septal defect. Septal myectomy of the calcified interventricular septum requires avoidance of ‘one-piece technique’ since fragmental myectomy allows visually control the adequacy of the left ventricle outflow tract release.

Intermediate-Term Outcome Following Plain Balloon Angioplasty of Discrete Near-Total or Total Occlusion of Aortic Coarctation

Objective:Surgical repair or stenting has been the standard treatment for patients with discrete near-total or total occlusion of aortic CoArctation (CoA) in both adolescents and adults. The role of plain Balloon Angioplasty (BA) as definitive therapy has not been well established in these patients due to the reported higher rates of complication and re-coarctation. The purpose was to evaluate intermediate-term outcome following BA of such patients by using different techniques in those patients where surgery or stenting was not possible. Materials and Methods:The data of 9 patients of such CoA treated with BA from January 2014 to December 2018 was analyzed. The approach for BA was retrograde in 4 patients and antegrade in 5 patients. Different stiff coronary hardware was used in some cases to cross the occluded segments and make the procedure successful. They were evaluated at a mean interval of 43 months (range 14-72 months). The assessment included clinical examination, echocardiography and cardiac catheterization as and when required. Results:The mean age of studied patients was 27.88 year (range 14–52 years). Immediate success was obtained in all patients with no early mortality or major complications. Peak systolic pressure gradient reduced from 79.117.11mmHg immediately. On follow-up, out of the 5 patients who had Doppler peak gradient of more than 20 mmHg, none had significant peak systolic gradient on catheterization. There was no mortality or serious complications on follow-up. Hypertension was completely relieved in 45% (4/9) and improved in 55% (5/9)patients. Conclusion:Balloon angioplasty of discrete near-total or total occlusion of native CoA by different method is safe and effective on the intermediate follow- up and can be considered in patients who are not candidates for surgery or stenting.

Validation and Diagnostic Performance of a CFD-Based Non-invasive Method for the Diagnosis of Aortic Coarctation.

Purpose: The clinical diagnosis of aorta coarctation (CoA) constitutes a challenge, which is usually tackled by applying the peak systolic pressure gradient (PSPG) method. Recent advances in computational fluid dynamics (CFD) have suggested that multi-detector computed tomography angiography (MDCTA)-based CFD can serve as a non-invasive PSPG measurement. The aim of this study was to validate a new CFD method that does not require any medical examination data other than MDCTA images for the diagnosis of CoA.Materials and methods: Our study included 65 pediatric patients (38 with CoA, and 27 without CoA). All patients underwent cardiac catheterization to confirm if they were suffering from CoA or any other congenital heart disease (CHD). A series of boundary conditions were specified and the simulated results were combined to obtain a stenosis pressure-flow curve. Subsequently, we built a prediction model and evaluated its predictive performance by considering the AUC of the ROC by 5-fold cross-validation.Results: The proposed MDCTA-based CFD method exhibited a good predictive performance in both the training and test sets (average AUC: 0.948 vs. 0.958; average accuracies: 0.881 vs. 0.877). It also had a higher predictive accuracy compared with the non-invasive criteria presented in the European Society of Cardiology (ESC) guidelines (average accuracies: 0.877 vs. 0.539).Conclusion: The new non-invasive CFD-based method presented in this work is a promising approach for the accurate diagnosis of CoA, and will likely benefit clinical decision-making.

Assessment of hemodynamic responses to exercise in aortic coarctation using MRI-ergometry in combination with computational fluid dynamics

In patients with aortic coarctation it would be desirable to assess pressure gradients as well as information about blood flow profiles at rest and during exercise. We aimed to assess the hemodynamic responses to physical exercise by combining MRI-ergometry with computational fluid dynamics (CFD). MRI was performed on 20 patients with aortic coarctation (13 men, 7 women, mean age 21.5 ± 13.7 years) at rest and during ergometry. Peak systolic pressure gradients, wall shear stress (WSS), secondary flow degree (SFD) and normalized flow displacement (NFD) were calculated using CFD. Stroke volume was determined based on MRI. On average, the pressure gradient was 18.0 ± 16.6 mmHg at rest and increased to 28.5 ± 22.6 mmHg (p < 0.001) during exercise. A significant increase in cardiac index was observed (p < 0.001), which was mainly driven by an increase in heart rate (p < 0.001). WSS significantly increased during exercise (p = 0.006), whereas SFD and NFD remained unchanged. The combination of MRI-ergometry with CFD allows assessing pressure gradients as well as flow profiles during physical exercise. This concept has the potential to serve as an alternative to cardiac catheterization with pharmacological stress testing and provides hemodynamic information valuable for studying the pathophysiology of aortic coarctation.

Balloon Angioplasty for Native Aortic Coarctation in 3- to 12-Month-Old Infants.

Balloon angioplasty for native coarctation of the aorta (CoA) is successful in children and adults but in neonates results in frequent restenosis. The efficacy of balloon angioplasty for native CoA during infancy beyond the neonatal period was examined in infants aged 3 to 12 months of age. A retrospective review of 68 infants who underwent balloon angioplasty for native CoA. 95% CI are in parentheses. Procedural age was (mean±SD) 6±3.4 months and weight was 7±1.8 kg. Balloon angioplasty produced a large decrease in both the noninvasive arm-to-leg blood pressure gradient (41.2±18.7 to 5.6±9.6 mm Hg) and the invasive peak systolic pressure gradient (34±12 to 11±9 mm Hg). Balloon angioplasty increased the CoA diameter from 2.7±1 mm to 4.6±1.2 mm. One patient was lost to follow-up. A catheter reintervention was required in 11.8% and surgery in 10.3%. The hazard of reintervention was highest early. Median freedom from reintervention was 89% (95% CI, 80%-96%) at 1 year, 83% (95% CI, 73%-92%) at 5 years, and 81% (95% CI, 69%-90%) at 10 years. Femoral artery thrombosis was documented in 6 (9%) infants without any long-term consequence. One patient developed a small aortic aneurysm late and has not required treatment. A robust estimate of the frequency of aortic aneurysms remains to be determined as the majority of subjects have not had cross-sectional imaging. Balloon angioplasty of native CoA is effective and safe in infants aged 3 to 12 months with outcomes comparable to those in older children and adults. Catheter reinterventions can avoid the need for surgery in most patients.

Valve-in-valve transcatheter aortic valve replacement on a self-expandable nitinol frame due to degeneration of primary bioprosthetic valve cusps. Clinical case of a high-risk surgical female patient

Introduction. We present the clinical observation of a 72-year-old female patient with high surgical risk and structural degeneration of a bioprosthetic aortic valve (AV) cusps in the form of stenosis, accompanied by severe dysfunction. Transcatheter implantation of bioprosthesis Medtronic CoreValve™ Evolut™ R-23 was performed using the valve-in-valve technique. The choice of minimally invasive treatment tactics is substantiated, a preoperative examination algorithm and a specific bioprosthesis model for such intervention are provided. Materials and methods. Imaging – echocardiography (Echo), electrocardiography, multispiral computed tomography, coronary angiography. Bioprosthetic valve calcification and stenosis with critical parameters of the bioprosthetic AV peak pressure gradient according to Echo data were the indications for minimally invasive surgery. Results. Dynamic observation revealed a progressive deterioration in the function of the previously implanted bioprosthetic heart valve in the aortic position, and a critical deterioration in the patient’s condition. After additional examination of the patient and selection of a new prosthesis, valve-in-valve transcatheter aortic valve replacement was done. The positive dynamics of the general state of the patient was noted in the early postoperative period. Echo data showed that the bioprosthetic AV peak systolic pressure gradient decreased from 90 to 29 mmHg, average gradient – from 42 to 19 mmHg. Conclusion. The minimally invasive valve-in-valve transcatheter aortic valve replacement used to correct the dysfunction of a bioprosthetic AV that was previously implanted during an open surgery was shown to be safe and effective and can be considered as one of the options for repeat valve replacement.

Percutaneous mechanical thrombectomy in patients with high-risk pulmonary embolism and contraindications for thrombolytic therapy.

BackgroundHigh-risk pulmonary embolism is associated with a high early mortality rate. We report our experience with percutaneous mechanical thrombectomy in patients with high-risk pulmonary embolism and contraindications for thrombolytic therapy.Patients and methodsThis was a retrospective analysis of consecutive patients with high-risk pulmonary embolism and contraindications to thrombolytic therapy. They were treated with percutaneous mechanical thrombectomy which included thrombectomy and additional thrombus aspiration when needed. Clinical parameters and survival to discharge were measured.ResultsFrom November 2005 to September 2015 we treated 25 patients with a mean age of 62.6 ± 12.7 years, 64% were men. Mean simplified Pulmonary Embolism Severity Index was 2.9. Mean maximum lactate levels were 7.8 ± 6.6 mmol/L, vasopressors were used in 77%, and 59% needed mechanical ventilation. Mechanical treatment included thrombus fragmentation complemented with aspiration (56%) and aspiration using Aspirex®S catheter (44%). Local (5 patients; 20%) and systemic (3 patients; 12%) thrombolytics were used as a salvage therapy. We observed nonsignificant improvements in systemic blood pressure (100 ± 41 mm Hg vs 119 ± 34; p = 0.100) and heart frequency (99 ± 35 min-1 vs 87 ± 31 min-1; p = 0.326) before and after treatment, respectively. Peak systolic tricuspid pressure gradient was significantly lower after treatment (57 ± 14 mm Hg vs 31 ± 3 mm Hg; p = 0.018). Overall the procedure was technically successful in 20 patients (80%) and 17 patients (68%) survived to hospital discharge.ConclusionsIn patients with high-risk pulmonary embolism who cannot receive thrombolytic therapy, percutaneous mechanical thrombectomy is a promising alternative to reduce pulmonary artery pressure.

Pulsed-wave doppler echocardiographic cardiac dimensions of Muzaffarnagari sheep

With the aim to determine reference pulsed-wave Doppler echocardiographic cardiac dimensions in sheep, transthoracic echocardiographic examination in right lateral position was performed in 20 healthy adult female Muzaffarnagari sheep. The study was conducted between August, 2014 and March, 2015 at ICAR-Indian Veterinary Research Institute, Izatnagar. The peak early (Emax) and late (Amax) transmitral filling velocities were 61.75±2.93 and 42.17±2.52 cm/s, respectively. The mean early (Emean) and late (Amean) transmitral filling velocities were 31.67±1.45 and 21.86±1.26 cm/s, respectively. The velocity time integrals of transmitral filling during early ventricular filling (VTIE) and atrial contraction (VTIA) were 8.22±0.29 and 4.52±0.39 cm, respectively. The peak early (PPGE) and late (PPGA) transmitral filling pressure gradients were 1.58±0.15 and 0.75±0.08 mmHg, respectively. The mean early (MPGE) and late (MPGA) transmitral filling pressure gradients were 0.42±0.04 and 0.20±0.02 mmHg, respectively. Early (ETE)andlate (ETA) transmitral filling ejection time were 0.27±0.01 and 0.21±0.02 s, respectively. Emax/Amax, VTIE: VTIA ETE: ETA and PPGE: PPGA ratios were 1.50±0.05, 2.11±0.23, 1.43±0.15 and 2.30±0.17, respectively. The peak (AOVmax), mean (AOVmean), velocity time integral (VTIAO), peak systolic pressure gradient (PPGAO), mean systolic pressure gradient (MPGAO), and ejection time (ETAO) of the aortic flow were 87.59±5.54 cm/s, 43.68±2.87 cm/s, 10.94±0.80 cm, 3.19±0.39 AO mmHg, 0.80±0.10 mmHg and 0.25±0.01s, respectively. These pulsed-wave Doppler echocardiographic cardiac dimension reference values in Muzaffarnagari sheep could serve as a reference for physiological and cardiovascular studies in this breed.

Successful balloon valvuloplasty of a subpulmonic membrane associated with cor triatriatum dexter: a case report

BackgroundSubpulmonic membrane as a cause of right ventricular outflow tract obstruction in patients with concordant ventriculoarterial connection and intact ventricular septum is considered to be rare. Association with cor triatriatum dexter and success of subpulmonic balloon valvuloplasty have never been reported, at least to the best of our knowledge.Case presentationA 3-year-old Moroccan boy was referred to our tertiary care hospital with complaints of dyspnea on moderate exertion. A physical examination revealed parasternal lift, systolic thrill, and a 4/6 ejection systolic murmur, best heard over the left second intercostal space. His oxygen saturation was 99% on room air. Two-dimensional echocardiography showed a discrete circumferential membrane just below the pulmonic valve and a right atrial membrane. Continuous wave Doppler interrogation showed peak systolic pressure gradient of 85 mmHg across the subpulmonic membrane and no significant gradient across the right atrial membrane. Balloon dilation of the subpulmonic membrane was performed and the pressure gradient came down to 50 mmHg. During follow-up, he reported marked improvement in terms of exercise tolerance. Transthoracic echocardiography showed residual pressure gradient of approximately 40 mmHg across the membrane. Surgery resection of the two membranes was programmed, but he died after an extracardiac disease (appendicular peritonitis).ConclusionsSubpulmonic membrane as an isolated cause of right ventricular outflow tract obstruction is rare. Its association with cor triatriatum dexter is even less common. The result of percutaneous balloon valvuloplasty of subpulmonic membrane is an interesting alternative while waiting for surgery. Surgery is currently the preferred modality of treatment with the resection of both right atrial and subpulmonic membranes.

Hematocrit: another important factor in systemic neonatal cardiovascular adaptation

Background: Global cardiovascular adaptation of normal healthy term newborns is rarely studied from a multiorgan and hematological point of view.Aims: To evaluate comprehensive neonatal cardiovascular adaptation during the first days of life with echocardiography and renal-cerebral echo color-Doppler and to correlate it with hematocrit (Ht) changes.Study design: A prospective observational study was conducted on 35 healthy term neonates with a mean ± SD gestational age and birth weight of 39.5 ± 1.1 weeks and 3,400 ± 330 g, respectively. All infants underwent serial echocardiograms at 15 ± 4 hours (day 1) and 72 ± 4 hours (day 3) of age. At the same time, cerebral and renal Doppler parameters were acquired and Ht was sampled.Results: The weight and Ht declined by 220 g (189-251) and 8.1% (6.7-9.5), respectively. Systolic and diastolic diameters of the right ventricle and diastolic left ventricle posterior wall thickness showed a reduction, while the diastolic diameter of the left ventricle showed a small increase. The Doppler cardiac evaluation showed an increase in the mitral E/A ratio and pulmonary acceleration time, a reduction of late transmitral flow peak velocity, aortic peak systolic velocity (PSV), aortic peak systolic pressure gradient, aortic velocity-time integral, aortic mean pressure gradient and pulmonary mean acceleration. We also found a reduction of cerebral resistance parameters and an increase in PSV, end-diastolic velocity, and time-averaged velocity. Other measured parameters remained unchanged.Conclusion: Systemic cardiovascular evaluation about changes in Ht is an essential approach to study newborns, especially during the first days of life when Ht shows a significant decrease. Knowledge of the laws of physics related to the effect of Ht changes on vascular parameters is another important factor in understanding the pathophysiology of neonatal disease states. Further studies are useful to help physicians make evidence-based decisions in the management of newborns in Neonatal Intensive Care Units (NICUs).

Long-term Prognostic Significance of Admission Tricuspid Regurgitation Pressure Gradient in Hospitalized Patients With Heart Failure With Preserved Ejection Fraction: A Report From the Japanese Real-World Multicenter Registry

BackgroundDoppler-estimated peak systolic tricuspid regurgitation pressure gradient (TRPG) is a representative noninvasive parameter for evaluating pulmonary artery systolic pressure, which can be a determinant of adverse outcomes in chronic heart failure with preserved ejection fraction (HFpEF). However, the prognostic implications of TRPG at admission for hospitalized patients with HFpEF are undetermined. Methods and ResultsWe examined 469 consecutive hospitalized patients with decompensated HFpEF (left ventricular ejection fraction ≥ 50%) who underwent TRPG measurement at admission in our HFpEF multicenter registry. The primary outcome of interest was all-cause death. Admission TRPG was significantly correlated with estimated pulmonary capillary wedge pressure and left atrial dimension (r = 0.24, P < 0.001 and r = 0.21, P < 0.001, respectively). During a median follow-up period of 748 (IQR 540–820) days, 83 patients died. Higher TRPG was significantly associated with higher mortality compared to lower TRPG (log-rank; P = 0.007). Multivariable analysis revealed that elevated TRPG was an independent determinant of mortality (HR 1.02, 95% CI 1.01–1.04, P = 0.008) after adjustment for prespecified confounders and renal function. ConclusionsElevated TRPG at admission was an independent determinant of mortality in hospitalized patients with HFpEF, indicating that TRPG at admission could be a useful marker for risk stratification in these patients.

Simplified Tricuspid Polytetrafluoroethylene Valved Conduit: Midterm Results of Multicenter Study

Conduit survival without significant dysfunction is important when selecting the right ventricular outflow tract conduit. We made an expanded polytetrafluoroethylene tricuspid valved conduit using a simplified technique. We aimed to investigate the midterm functional results and longevity of this conduit. Between November 2008 and December 2016, four hospitals in Korea implanted 145 valved conduits. We retrospectively analyzed their functional results and longevity. The patients' median age at operation was 36.6 months; the median body weight was 11.3 kg. The mean follow-up duration was 32.3 ± 24.5 months. There were four inhospital deaths and three late deaths, but there were no conduit-related deaths. The mean peak systolic pressure gradient across the conduit was 14.7 ± 8.3 mm Hg and 31.6 ± 17.7 mm Hg at discharge and last follow-up, respectively. Six patients (4.4%) had moderate or more conduit valve regurgitation at last follow-up. Conduit dysfunction was observed in 30 patients (21.9%), mainly caused by increased pressure gradient (24 of 30, 80%). Freedom from conduit dysfunction was 88.1% and 58.5% at 3 and 5 years, respectively. Lower freedom from conduit dysfunction was observed in small conduits. Eleven patients (7.8%) underwent conduit explantation, and freedom from explantation was 94.8% and 81.7% at 3 and 5 years, respectively. The main cause of explantation was conduit stenosis. Small conduits tended to have lower freedom from explantation. Functional results and longevity of our expanded polytetrafluoroethylene tricuspid valved conduit are acceptable. Although our conduits tend to have increasing pressure gradient over time, especially in small conduits, they have low incidence of moderate or more regurgitation.

Echocardiographic Estimation of Pulmonary Artery Pulsatility Index in Pulmonary Hypertension

Purpose Pulmonary Artery Pulsatility Index (PAPi) has been studied extensively in predicting right ventricular failure after left ventricular assist device implantation and in those with inferior wall myocardial infarction. More recently, this physiologic index has shown prognostic value in the setting of pulmonary arterial hypertension and advanced heart failure. We hypothesize that an echocardiographic estimation of PAPi will correlate with the index derived from right heart catheterization (RHC). Our goal is to enhance the echocardiographic examination to determine a physiologic parameter currently limited to invasive hemodynamic assessment. Methods This was a single center, retrospective observational study of twenty patients that had underwent RHC and transthoracic echocardiography within a two week timeframe. The study was performed via retrospective chart review conducted at Allegheny General Hospital. Echocardiograms were reviewed by a single observer that was blinded to all recorded invasive hemodynamic measurements. PAPi was estimated by the standard calculation used in invasive hemodynamic assessment. Individual intracardiac pressures were obtained via inferior vena cava diameter and collapsibility, peak systolic pressure gradient of the tricuspid regurgitant jet, and end diastolic pressure gradient of the pulmonic regurgitant jet. Correlation between invasive and noninvasive indices was assessed via Pearson's test. Results Pearson's coefficient (r) showed a positive correlation with r = 0.63. There was improved correlation at lower index values (see Graph 1). Conclusion Calculation of PAPi appears to be feasible via echocardiographic estimation. Given the impact of this index in assessment of right ventricular function, further investigation of the above findings may provide benefit in the setting of pulmonary hypertension and congestive heart failure.