Poor Echo Window Research Articles

Transcatheter closure of atrial septal defect (ASD) in adult and paediatric population without transoesophageal echocardiography/general anaesthesia

Abstract Background Transcatheter device closure is the preferred therapeutic option for ostium secundum atrial septal defect(OS-ASD). Standard practice is to perform it under transoesophageal echocardiography(TEE) guidance. However, TEE is performed under general anaesthesia (GA) and leads to increases in cost, procedural duration, ICU stay, total hospital stays, risk of oesophageal injury and complications of GA. Transthoracic echocardiography(TTE) is an excellent alternative and prior studies have shown it to be a safe alternative in paediatric population. In current study we analysed safety and efficacy of TTE-guided device closure of OS-ASD in all comer population irrespective of age, weight, defect size. Methods The study enrolled all patients who underwent device closure of OS-ASD between March 2017 and December 2023. All procedures were performed under LA for adults and conscious sedation for children. The device was placed under fluoroscopy guidance and position were confirmed on TTE. Procedural success, device, defect size ratio, procedural time, fluoroscopy time, complications, intensive care unit/hospital stay duration were analysed and compared with our own experience of 125 patients with TEE-guided closures before switching to complete TTE-guided procedure(before 2017). Results 340 patients underwent TTE-guided device closure of ASD. Procedure success was 97.4% with acceptable risk of major complications. Three(0.8%) had embolization into pulmonary artery, successfully operated surgically. Two had tamponade requiring drainage. In 9 patients, device could not be deployed despite multiple attempts and approaches. All of these had defect size of > 34mm and deficient IVC rim along with shorter (other than aortic) rim. Findings were compared with our own previous experience of TOE guided closure (practised before 2017). Compared to TOE group, TTE group had significantly lower total procedural duration (75±4 vs. 28 ±1 min; p < 0.01), intensive care unit stay (24±10 vs. 10.5±1 h; p < 0.01), and hospital (48±12 vs. 25.5±4h; p < 0.01) stay duration. Fluoroscopic time was similar in both. There was no mortality in either group. Major complications were comparable, TTE-guided group had less post-procedure complications of vomiting and headache. Additional findings of less pre-procedure fasting duration and early commencement of post procedure oral intake were noted in TTE group. Conclusion TTE-guided device closure of OS-ASD is a safe and feasible in all-comer population in experienced hands. It can definitely negate the use of TEE except in very poor echo window. The added advantages include utilization of physiological variations in PV/LV pressure during cough, Valsalva manoeuvres in awake patients. It definitely reduces the procedural duration, cost of procedure and dependence on GA and trained transoesophageal echocardiographer.

Correlation of Aortic Root Movement with Left Ventricular Function

Objectives: The motion of structures of the heart is the basis for cardiac function. Factors such as low image quality and low signal-to-noise ratio create hindrances in the adequate valuation of left ventricular (LV) systolic and diastolic function. Even in cases with poor image quality, the aorta being a large structure is well visualized. One of the unorthodox approaches to the assessment of heart function is the study of aortic root movement. Materials and Methods: We studied patients who came to the Nizam Institute of Medical Sciences. The ethics committee of the institute approved our study. We studied 85 patients who came to the emergency or outpatient department with or without various cardiovascular problems. We have included patients who presented with myocardial infarction, arrhythmia, and heart failure, cerebrovascular accident. We measured the constants pertaining to the aortic root motion and LV function with the standard parameters of echocardiography. Then, we aimed to check for a correlation between aortic root movement parameters and the LV function of the heart. Patients filling the inclusion criteria were enrolled in the study after taking informed consent. The data from the participants were collected prospectively. We recorded the echocardiography according to the standard guidelines. We used the Vivid E9 scanner (GE Vingmed Ultrasound AS) with the M5S-D (1.7–3.3 MHz) cardiac probe to acquire the data. We studied the echocardiographic 2D images and Doppler parameters. We used the parasternal long axis view as well as the parasternal short axis view to measure the aortic movement. Results: We included a total number of 85 patients as per the defined criteria among which 22 (25.88%) are females and 63 (74.11%) are males. The average age of enrolled participants was 56.30 years (±14.95 years). The mean age of the patients was 56.3 ± 14.9. About 75% of the subjects had LV dysfunction and the remaining had normal lv function. Sixty-five patients had LV dysfunction either due to ischemic or non-ischemic cardiomyopathy. We, then, checked for the relationship between the aortic root constants and the LV function parameters. We found the mean value of aortic root diastolic distance (ARDD) as 2.59 ± 0.43 cm and. The aortic root maximal diastolic velocity (ARDV) was 10.8 ± 2.4 cm/s. The aortic root systolic distance (ARSD) was 2.71 ± 0.65 cm. The aortic root maximal systolic velocity (ARSV) was 7.92 ± 2.26 cm/s. Mean aortic root excursion was 4.3 mm. Aortic root systolic excursion (ARSE) showed a parallel relation with LV function (r up to 0.7). We found ARSD and ARSV correlating weakly with systolic Doppler parameters, such as ejection fraction (EF), maximum annular plane systolic excursion (MAPSE), and s' medial. ARSE was an exception that it showed a good correlation with s’medial r = 0.746 (P < 0.001), EF r = 0.807 (P < 0.001), and MAPSE r = 0.68 (P < 0.001). The ARDD and ARDV related poorly with LV diastolic parameters such as e' mean, e' medial, e' lateral, E/A, and E/e’. E velocity, E/A, and E/e’mean showed a negative correlation with ARDV. ARDD (r up to 0.02) and ARSD (all r values < 0.40) did not correlate with the LV Doppler measurements. ARDV correlated (r up to 0.51) with some LV diastolic Doppler parameters and ARSV correlated in moderate range only with mitral annulus plane systolic excursion (r = 0.31). In fact, we found that ARDD is related better than ARDV with Doppler measurements. Conclusion: In our study, we included subjects with cardiovascular diseases and we conclude that systolic aortic root motion correlates significantly with systolic LV function, the most essential being the aortic root systolic velocity. We found that the diastolic root motion parameters correlated weakly with the diastolic LV function. In patients with poor echo windows, aortic root motion may be helpful in predicting LV function in patients with or without LV dysfunction.

Extended Role of Parametric Mapping with Cardiac Magnetic Resonance in the Evaluation of Endomyocardial Fibrosis – Our Initial Experience

Endomyocardial fibrosis (EMF) affects approximately 12 million persons worldwide and is an important cause of restrictive cardiomyopathy in the developing world, with the highest prevalence reported in sub-Saharan Africa, South Asia, and South America. EMF is characterized by apical infiltration with fibrotic tissue in one or both ventricles, often associated with thrombus in early stage of the disease, calcification in late stage of the disease, and typical symptoms of restrictive heart failure. Clinical evaluation, transthoracic echocardiography, and characteristic Doppler findings of restrictive physiology are sufficient to diagnose EMF in most of the cases. However, few cases may require cardiac magnetic resonance due to poor echo window or shadowing due to apical calcification. Tissue characterization ability of cardiac magnetic resonance imaging has evolved further in the era of parametric mapping. We plan to showcase the incremental value of parametric mapping (T1/T2 mapping) in staging, prognostication, and management in two cases of EMF.

Applying Resting Global Longitudinal Strain by Two-Dimensional Speckle Tracking as a Noninvasive Diagnostic Tool in Predicting Coronary Artery Disease

Background: Two-dimensional speckle-tracking echocardiography (2D STE) has been used by many cardiologists globally for assessing the left ventricle (LV) function by having global longitudinal strain (GLS) as an important parameter; however, it is not incorporated into daily practice and some studies have proved to be a better diagnostic value for evaluation of detecting significant coronary artery disease (CAD) and also in predicting the culprit coronary artery. Methods: We enrolled 100 consecutive symptomatic patients with suspected CAD who have undergone angiogram in our institute. Out of these, 21 patients had poor echo window and were excluded. The patients were divided into two groups those presenting with acute coronary syndrome ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and others with stable angina. All patients underwent a 2D echocardiogram, 2D strain imaging, and coronary angiogram. Results: GLS correlated well with ejection fraction in our study. GLS was more impaired in patients with double- and triple-vessel disease than in patients with single-vessel disease. The number of patients presented with STEMI is 26 (anterior wall myocardial infarction – 20 and inferior wall myocardial infarction – 6), 23 had NSTEMI, and 30 had stable angina. The results of regional peak systolic strain had a stronger correlation with coronary angiogram in stable angina (P = 0.03), but in ACS patients, it was not significant (P = 0.136). This correlation was better in patients with adequate LV systolic function (P < 0.05) than patients with left ventricular systolic dysfunction (P = 1.0). Conclusion: 2D STE is a simple, noninvasive, and reproducible diagnostic tool in the evaluation of CAD and is immensely helpful in the localization of culprit vessel in chronic coronary syndrome.

Agitated Saline Contrast Echocardiogram In Cardio-Pulmonary Evaluation

Agitated saline contrast echocardiogram (ASC) is a very useful technique to detect various intracardiac and extra cardiac shunts in daily cardiology practice . Conventional 2D and color echocardiogram may not be well effective in ruling out various intracardiac shunts especially with patients having poor echo window. The introduction of agitated saline with bubbles formed during the study can help delineate different right to left shunt physiology commonly like patent foramen ovale (PFO) which is often sought for in evaluation of cases with young stroke . Various other etiologies like atrial septal defects, atrial septal aneurysm, large right to left shunts with eisenmengerisation can also be evaluated with this simple bedside study.

P5554Follow the light - The prognostic value of late gadolinium enhancement in hypertrophic cardiomyopathy

Abstract Background and aim Hypertrophic cardiomyopathy (HCM) is a genetic based cardiomyopathy with heterogeneous phenotypic expression. Since it is one of the most common cause of sudden cardiac death (SCD) in the young different risk score have been proposed to properly identify the patients that would benefit from a primary prevention with an implantable cardioverter-defibrillator (ICD). ESC guidelines on HCM suggest to estimate the risk of SCD considering clinical and echocardiographic parameters and mention the use of cardiac magnetic resonance (CMR) only in the case of poor echo windows. The aim of the present study-level meta-analysis was to explore the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) for adverse fatal events. Methods We searched PubMed and EMBASE for studies that investigated the prognostic value of LGE in patients with HCM. The outcomes of interest were SCD or aborted SCD, all-cause mortality and cardiovascular (CV) mortality. Random-effects Odds Ratios (ORs) were estimated using a DerSimonian-Laird method with a person-year approach. Moreover, an univariate meta-regression was performed to assess the moderator effect of mean age, LGE % of left ventricle (LV) and gender (expressed as male percentage). Results A total of 7 studies (n=3351) were included in the analysis. Mean follow-up was 3±0.63 years. Mean age was 47.7±14.6 years and 56.9% were male. LGE was detected in 1845 (55%) patients with a mean LGE percentage of LV of 7%. The presence of LGE was associated with an increased incidence of SCD or aborted SCD (OR 3.44; 95% CI 2.02–5.86; p<0.001- Figure), all-cause mortality (OR 1.92; 95% CI 1.31–2.81; p<0.001) and CV mortality (OR 3.16; 95% CI 1.77–5.64; p<0.001) compared with the absence of LGE at CMR. The LGE percentage of LV, mean age and gender did not have any moderator effect on the outcomes of interest. However, LGE % of LV was reported only in 4 studies and the absence of any moderator effect of this parameter could be due to a type II error. Prognostic value of LGE for SCD Conclusions The presence of LGE at CMR in patients with HCM exhibited a substantial prognostic value in fatal events and, in particular, in the prediction of SCD. LGE assessment is an effective tool to stratify the arrhythmic risk in HCM. Therefore, it should be considered, especially in borderline cases, to improve the identification of HCM patients who could benefit from ICD implantation.

Feasibility of myocardial perfusion assessment with contrast echocardiography: can it improve recognition of significant coronary artery disease in the ICU?

BackgroundDiagnosis of significant coronary artery disease (CAD) and acute coronary artery occlusion in ICU can be difficult, and an inappropriate intervention is potentially harmful. Myocardial contrast perfusion echo (MCPE) examines ultrasound contrast intensity replenishment curves in individual myocardial segments measuring peak contrast intensity and slope of return as an index of myocardial blood flow (units = intensity of ultrasound per second [dB/s]). MCPE could possibly serve as a triage tool to invasive angiography by estimating blood flow in the myocardium. We sought to assess feasibility in the critically ill and if MCPE could add incremental value to the clinical acumen in predicting significant CAD.MethodsThis is a single-centre, prospective, observational study. Inclusion criteria were as follows: adult ICU patients with troponin I > 50 ng/L and cardiology referral being made for consideration of inpatient angiography. Exclusion criteria were as follows: poor echo windows (2 patients), known ischaemic heart disease, and contrast contraindications. Seven cardiologists and 6 intensivists blinded to outcome assessed medical history, ECG, troponin, and 2D echo images to estimate likelihood of significant CAD needing intervention (clinical acumen). Clinical acumen, quantitative MCPE, and subjective (visual) MCPE were assessed to predict significant CAD.ResultsForty patients underwent MCPE analysis, 6 (15%) had significant CAD, and median 11 of 16 segments (IQR 8–13) could be imaged (68.8% [IQR 50–81]). No adverse events occurred. A significant difference was found in overall MCPE blood flow estimation between those diagnosed with significant CAD and those without (3.3 vs 2.4 dB/s, p = 0.050). A MCPE value of 2.8 dB/s had 67% sensitivity and 88% specificity in detecting significant CAD. Clinical acumen showed no association in prediction of CAD (OR 0.6, p = 0.09); however, if quantitative or visual MCPE analysis was included, a significant association occurred (OR 17.1, p = 0.01; OR 23.0, p = 0.01 respectively).ConclusionsMCPE is feasible in the critically ill and shows better association with predicting significant CAD vs clinical acumen alone. MCPE adds incremental value to initial assessment of the presence of significant CAD which may help guide those who require urgent angiography.

Transesophageal Echocardiography Examination in Ailuropoda melanoleuca.

Cardiac function analysis for Ailuropoda melanoleuca, also called giant panda, with transthoracic echocardiography has several limitations, such as limited probe position area and poor echo window. We want to determine the feasibility of transesophageal echocardiography (TEE) for cardiac examination in Ailuropoda melanoleuca. Eight-year-old male Ailuropoda melanoleuca was anesthetized by intramuscular ketamine and followed by inhalation isofl urane with spontaneous respiration. TEE probe was inserted through mouth. Comprehensive examinations were done by two-dimensional (2D), Doppler method, 3D zoom and 3D full volume mode for their cardiac evaluation. The structure of heart was similar to human. We found mild mitral regurgitation. Right ventricle and pulmonary artery were free of any organic lesions. We did comprehensive multiplane examination by American Society of Echocardiography/Society of Cardiovascular Anesthesia guideline, but transgastric (TG) and deep TG view were not approachable. 3D reconstruction offered high quality image and quantitative calculations. Complete examinations took less than 30 minutes. There was no significant hemodynamic change during probe insertion, and no oropharyngeal trauma certifi ed by dentist. TEE is a reasonable semi-invasive tool for cardiac function evaluation. Though some anatomical limitations prohibited comprehensive 2D views, improvements such as 3D images help to give detailed cardiac examination.

Conventional Two-Dimensional Echocardiography Versus Contrast Echocardiography in the Assessment of Left Ventricular Volumes and Function in Patients with Poor Acoustic Window

Aim: To compare the number of left ventricular (LV) segments visualized, detection of regional wall motion, and LV volumes and function with conventional two-dimensional echocardiography versus that with contrast echocardiography in patients with poor acoustic windows. Materials and Methods: This was a prospective study done over a duration of 1 year, on 50 consenting patients with poor echocardiographic image quality. Basic information and baseline echocardiograms were recorded. SonoVue contrast was administered intravenously as per a preset protocol through a peripheral line, and LV endocardial border delineation was recorded in various comparable views. Results: There was a significant change in the quality of the echocardiographic images postcontrast enhancement, with no study images remaining uninterpretable and only 16% remaining technically difficult. The remaining studies became adequate in terms of endocardial border delineation. Myocardial segment visualization changed significantly after contrast, with the number of well-visualized segments per patient improving from 10.66 before contrast to 16.26 after contrast, on average. There was a significant change in the estimation of LV volumes after contrast administration. The biplane ejection fraction was also significantly different after contrast. The study detected new regional wall motion abnormalities in 10 (20%) patients out of the total 50. There was only one case of an adverse event in terms of three isolated ventricular premature complexes in one of the patients after contrast administration. Conclusion: Contrast echo appears to be an easy, safe, and reliable investigation in patients with poor echo windows. Our study shows that endocardial border delineation is best with contrast enhancement, which improves physician's confidence and hence can impact the overall diagnosis, management, and prognosis of patients based on the better and reliable echo findings.

Evaluation of sepsis induced cardiac dysfunction as a predictor of mortality

BackgroundSepsis is characterized by life threatening organ dysfunction with dysregulated immune response. Cardiac dysfunction seen in sepsis is unique as it is reversible within 7–10 days. Initial study by Parker et al. in 1984, showed, paradoxically lower ejection fraction in survivors of septic shock. Subsequent meta-analysis did not support that survivors had lower ejection fraction. Aim of our study was to assess the sepsis induced cardiac dysfunction by 2D echocardiography and Troponin I.MethodsAfter obtaining institutional ethical committee approval (ref 125/2016), a prospective observational study was done in an university medical college from February 2016 to April 2016. Inclusion criteria were patients diagnosed with sepsis by new sepsis definition. Pregnant patients and patients with poor echo window were excluded. Echocardiographic assessment was done within 48 h of diagnosis of sepsis by standard methods. Primary outcome was ICU mortality and secondary outcome was ICU length of stay. Statistical analysis was done using STATA™ (Version14, College station TX).ResultsFifty eight patients were screened, ten were excluded due to poor echo window. Baseline characteristics were similar in survivors and non survivors, except APACHE II, SOFA age and cumulative fluid balance. Echocardiographic parameters, mitral annular plane systolic excursion (MAPSE), E/e’ and LV systolic function assessed by visual gestalt method were found to be statistically significant. Parameters found significant in bivariate analysis were used as a covariate in logistic regression. APACHE II and MAPSE were significant co-variates in logistic regression with ROC (0.95) and calibration was satisfactory (chi2(df8),1.98, p = 0.98).ConclusionsSepsis induced cardiac dysfunction assessed by echocardiography showed measurement of MAPSE when combined with APACHE II was a good predictor of mortality. Among the echocardiographic parameters MAPSE alone was a good predictor of mortality. Results of this study need further validation from larger study.

Role of Mitral Leaflet Separation Index (MLSI) in Determining Mitral Stenosis Severity

Objective. To Correlate MLSI with 3-D mitral valve area (MVA) planimetry in determining mitral stenosis (MS) severity.Background. Mitral Stenosis (MS) is still a major problem in cardiology, and causes of morbidity dan mortality worldwide. Echocardiogrphy plays an important role in assessing mitral stenosis severity. Mitral leaflet separation index (MLSI) is one of simple method that can be used in peripheral by using common ultrasound to assess the severity mitral stenosis.Methods. We employed a cross sectional study. Mitral stenosis patients who referred for evaluation echocardiography in National Cardiac Center Harapan Kita from April to September 2011. MLSI was obtained by averaging the maximal leaflet separation distance at the tips in diastole in parasternal long-axis and apical four- chamber views. 3-Dimensional (3-D) mitral valve area (MVA) planimetry as a reference. The only exclusion criteria was severe calcification and poor echo window. Echocardiography examination using Philips E33i.Results. Seventy six consecutive patients were enrolled, 5 subjects were excluded from study because of severe calcification and poor echo window. Proportion of woman is 73.2 % and mostly in age group < 40 years old (43.7 %). Severe mitral stenosis was dominate the subject, 47 subject (66.2 %), moderate was 19 subject (26.8 %), and mild only 5 subjects (7.0 %). Analysis with Spearman correlations obtained a good correlation with r = 0.70, p < 0.001, good correlation was found in sinus rhythm with r = 0.78, p < 0.001 and atrial fibrillation with r = 0.79, p < 0.001. MLSI less than 0.69 cm predicted severe MS with 85 % sensitivity and 82.4 % specificity.Conclusions. Mitral leaflet separation index (MLSI) has a good correlation with 3-D MVA planimetry. MLSI less than 0.69 cm can estimate severe SM.

Comparative evaluation of central venous pressure and sonographic inferior vena cava variability in assessing fluid responsiveness in septic shock.

Objective:Fluid infusion, the most critical step in the resuscitation of patients with septic shock, needs preferably continuous invasive hemodynamic monitoring. The study was planned to evaluate the efficacy of ultrasonographically measured inferior vena cava collapsibility index (IVC CI) in comparison to central venous pressure (CVP) in predicting fluid responsiveness in septic shock.Materials and Methods:Thirty-six patients of septic shock requiring ventilatory support (invasive/noninvasive) were included. Patients with congestive heart failure, raised intra-abdominal pressure, and poor echo window were excluded from the study. They were randomly divided into two groups based on mode of fluid resuscitation – Group I (CVP) and Group II (IVC CI). Primary end-points were mean arterial pressure (MAP) of ≥65 mmHg and CVP >12 mmHg or IVC CI <20% in Groups I and II, respectively. Patients were followed till achievement of end-points or maximum of 6 h. Outcome variables (pulse rate, MAP, urine output, pH, base deficit, and ScvO2 ) were serially measured till the end of the study. Survival at 2 and 4 weeks was used as secondary end-point.Results:Primary end-point was reached in 31 patients (15 in Group I and 16 in Group II). Fluid infusion, by either method, had increased CVP and decreased IVC CI with resultant negative correlation between them (Pearson correlation coefficient –0.626). There was no significant difference in the amount of fluid infused and time to reach end-point in two groups. Comparison in outcome variables at baseline and end-point showed no significant difference including mortality.Conclusion:CVP and IVC CI are negatively correlated with fluid resuscitation, and both methods can be used for resuscitation, with IVC CI being noninferior to CVP.

Circumferential Calcified Thrombus in a Basal Lateral Wall Pseudo-aneurysm

An 83 year-old arteriopathic patient was investigated for shortness of breath. Transthoracic echocardiography images were suboptimal with poor echo windows. An echo-bright ‘extracardiac’ structure compressing the basal lateral region of the left ventricle and left atrium was noted. Further imaging was requested to characterise the lesion. Cardiac magnetic resonance imaging revealed appearances consistent with an extensive infero-lateral myocardial infarction. (Supplementary imagecine loop). There was a large mass (3.4cmx5.5 cm) in the basal lateral wall which abutted and partially compressed the posterior mitral valve leaflet. The mass revealed low signal intensity on steady state free processing (Fig B). There was also a low signal circumferential rim to the mass. (Figure C, fat suppression sequence) These appearances strongly suggested intramyocardial organised

An unusual cause of dyspnoea in a young man

A 20-year-old man presented with progressive exertional dyspnoea. His cardiovascular examination was unremarkable. The electrocardiogram showed sinus rhythm with a dominant R-wave in the early precordial leads and lateral Q-waves ( Panel A ). Laboratory investigation demonstrated elevated creatine kinase with normal Troponin-T levels. Echocardiography was non-diagnostic due to poor echo-windows. Cardiac magnetic resonance imaging showed mild hypokinesis of the …

Association between regional right ventricular dysfunction and thrombus location in patients with acute pulmonary embolism

Patients and methods From January 2007 through May 2013, 65 patients were diagnosed with acute PE based on CT scan in emergency department. We analyzed retrospectively transthoracic echocardiogram(TTE) of these patients who were performed TTE during admission. 3 patients were excluded because of indeterminable echocardiographic findings due to poor echo window. According to the location of the thrombus based on the CT scan, 62 study subjects were classified into three groups such as main, lobar and segmental pulmonary artery(PA) thrombus group. We investigated the association between McConnell’s sign and thrombus location.

Diffuse mural thrombus in a patient with thoracic aortic aneurysm

window in assessment of the LV apex lack of knowledge about this uncommon disease. Case report: A 29-year-old male with history of atypical chest pain was referred to our clinic. During his evaluation, intracardiac mass was discovered on a routine echocardiogram. There were no other symptoms of heart failure or coronary artery disease. Patient had no family history of heart disease or sudden death. On admission his physical examination was unremarkable. The 12-lead electrocardiography (ECG) showed normal sinus rhythm. Transthoracic echocardiogram and cardiac magnetic resonance imaging (MRI) were performed. Echocardiogram revealed a prominent cystic mass in the apical interventricular septum with normal left ventricular function, and color-doppler showed no flow within the cystic mass (Figure 1). MRI showed a typical pattern of noncompacted myocardium predominantly of the left ventricle (LV). Ratio of noncompacted to compacted area was 2.7 (pathological >2) (Figure 2). The LV was mildly dilated with preserved systolic function (LVEF: 50%). The ambulatory ECG documented sinus rhythm. There were no atrial fibrillation and ventricular arrhythmias. Lacking indications for more aggressive therapy, chronic anticoagulation with warfarin was prescribed. The patient was considered for regular follow-up to include assessment of exercise tolerance, measurement of ventricular size and function, and use of continuous ambulatory ECG. First degree relatives were screened with echocardiography. Discussion: Noncompaction of the ventricular myocardium is a recently recognized genetic cardiomyopathy. The prevalence is 0.014% of patients referred to the echocardiography laboratory, but the true prevalence is unclear. Clinical manifestations may range from being asymptomatic to presenting with heart failure, malignant arrhythmias, sudden cardiac death, or systemic thromboembolism. Echocardiography is the method of choice in establishing the diagnosis of ILVN. However, echocardiography depends on the experience and knowledge of the investigator and has poor echo window in assessment of the LV apex, which is the most commonly noncompacted area. MRI is especially useful when the myocardial involvement is subtle, and better distinguishes the compacted and non-compacted myocardial layers than echocardiography. In our patient, echocardiography revealed a cystic mass in the interventricular septum, but the MRI showed a typical pattern of noncompacted myocardium. Although echocardiography is the diagnostic method of ILVN, this case highlights the diagnostic benefits of MRI over echocardiography.

Echocardiographic predictors of coarctation of the aorta

Echocardiography is the main diagnostic modality of coarctation of the aorta especially in infants less than 3 months. Sometimes it is difficult to diagnose coarctation of the aorta either because of poor echo window or because of the presence of a large PDA. Failure or delay in the diagnosis of coarctation will lead to morbidity as well as mortality. The objectives of our study were to look for echocardiographic predictors of coarctation of the aorta. During the period from September 2010 to July 2011 echocardiographic measurements were performed for 67 normal infants referred for echocardiography. This was compared with 37 patients with proved coarctation either by surgery or cath. Echocardiographic measurements performed in both groups include aortic annulus, ascending aorta diameter, proximal transverse arch diameter, distal transverse arch diameter, aortic isthmus diameter, distance between aortic arch branches. Aortic valve anatomy , associated findings as well as surgical and cath diagnosis were reviewed. The ratio between the transverse arch and ascending aorta as well as between transverse arch and the distance between aortic arch branches were calculated. We compared both groups using SPSS statistical software. Measurements were done online as well as offline. During the study period 67 normal infants and 37 infants with coarctation were reviewed. The age group were from one day to one year and the mean weight were 4.48 ± 1.67 and 3.8 ± 2.19 kg for the normal and abnormal groups, respectively. There were no statistical difference between the two groups regarding the age weight as well as the gender. There were statistical difference in the echocardiographic measurements between the two groups regarding the transverse arch diameter with a smaller diameter in the CoA group (3.89 ± 1.17 vs 5.8 ± 1.05 mm, P value 0.0001). The ratio between the transverse arch and the ascending aorta was smaller in patients with CoA (0.55 ± 0.16 vs 0.73 ± 0.16, P value 0.0001). The distance between the left common carotid and the left subclavian arteries was longer in patients with CoA compared to those with normal arch (4.76 ± 2.37 mm vs 2.85 ± 1.59 mm, P value 0.0012). The ratio between the distance between the left common carotid and the left subclavian arteries to that of the transverse aortic arch diameter was higher in patients with Co (1.3311 ± 0.71 vs 0.54 ± 0.29, P value 0.0001). Bicuspid aortic valve was found in 57% of patients with CoA compared to only 6.5% of patients without coarctation (P value 0.0001). Echocardiographic predictors of coarctation of the aorta include the presence of bicuspid aortic valve, hypoplasia of the transverse arch, smaller ratio between the transverse arch and the ascending aorta and high ratio between the distance between aortic arch branches and transverse aortic arch.

Visceral Obesity of the Heart: Extensive Lipomatous Hypertrophy of Interatrial Septum

A 65-year-old woman was referred to the Department of Cardiovascular Surgery of our hospital for an operation with a presumptive diagnosis of right atrial myxoma. The mass was found incidentally on routine echocardiography during preoperative evaluation for total knee replacement. She had had hypertension and diabetes mellitus for 8 years. Her waist circumference was 111 cm and her body mass index was elevated at 37.8 kg/m2. She complained of mild exertional dyspnea. Electrocardiogram revealed normal sinus rhythm. Transthoracic echocardiography showed normal left ventricular dimensions and systolic function. However, it showed a poor echo window due to morbid obesity. Transesophageal echocardiography demonstrated a large right atrial mass attached to the interatrial septum with protrusion into the right atrium. The mass had a characteristic dumbbell-shaped appearance, separating into two parts (31 × 15 mm, 40 × 11 mm) due to sparing of the fossa ovalis (Fig. 1A and B). It was non-mobile and homogeneous echogenicity with a smooth surface. Fat tissue was also prominent around the aortic root. Cardiac magnetic resonance revealed a dumbbell shaped mass with no contrast enhancement involved on the interatrial septum from the coronary sinus to aortic root level. Subcutaneous, pericardial and epicardial fat tissue was revealed considerably (Fig. 1C). The mass showed high signal intensity on T1 weighted image (Fig. 1D) and dark signal on fat suppression image. Therefore, this obese woman did not undergo open heart surgery because her diagnosis on a multimodality imaging was extensive lipomatous hypertrophy of interatrial septum (LHIS). Fig. 1 Two-dimensional (A) and three-dimensional (B) transesophageal echocardiography showed dumbbell-shaped mass with sparing of the fossa ovalis. The mass (arrow) with no contrast enhancement involved on the interatrial septum in cardiac magnetic resonance ... LHIS is usually a benign condition caused by the excessive deposition of adipose tissue in the interatrial septum.1-3) It most often detected as an incidental finding on echocardiography in elderly obese patients. To avoid unnecessary surgical resection, we should consider this disease especially in elderly obese women.

Assessment of mitral annular velocities by Doppler tissue imaging in predicting left ventricular thrombus formation after first anterior acute myocardial infarction

Abstract Introduction This study was carried out in cardiology department, Zagazig University from August 2005 to December 2006. This study included 60 patients with first acute anterior myocardial infarction. These patients were 36 male (72%) and 14 female (28%). Aim of the work The aim of this study is to determine whether early assessment of mitral annular velocities by pulsed wave tissue Doppler imaging predicts left ventricular thrombus formation after first acute anterior myocardial infarction or not. Patients and methods Patients included in our study represented by first time anterior wall acute myocardial infarction who met the following criteria; chest pain lasting more than 30 min, ST segment elevation greater than 2 mm in two consecutive anterior electrographic leads and transient elevation of biochemical cardiac markers. Patients were excluded if they had evidence of previous anterior myocardial infarction, valvular heart disease, patients with poor Echo window and conduction abnormalities. All patients were subjected to the following: complete history taking, thorough physical examination, laboratory tests, 12-lead surface ECG, determination if the patient was received thrombolytic therapy or not and echocardiographic evaluation (M-mode, two-dimensional and DTI assessment) was performed for all patients within 24 h of arrival to CCU to evaluate LV function and to measure mitral annular velocities then two-dimensional echocardiography to determine thrombus was formed on days 7 and 30. Patients were divided into two groups: group (1); patients with LV thrombus (19 patients “31.6%”) and group (2); patients without LV thrombus (41 patients “68.4%”). Results There was no significant difference between the two groups as regards age, gender, diabetes mellitus, hypertension, heart rate, peak CPK and whether patients received thrombolytic therapy or not. LVESV and LVEDV were higher in group (1) than in group (2) while EF was lower in group (1) than in group (2). As regards WMSI is higher in group (1) than in group (2). E wave velocity was higher in group (1) than in group (2), while A wave velocity was lower in group (1) than in group (2) and E/A ratio is higher in group (1) than in group (2). Deceleration time of E wave was shorter in group (1) than in group (2) and IVRT were lower in group (1) than in group (2). Em wave velocity was lower in group (1) than in group (2), Am wave velocity had no significant difference between the two groups while Em/Am ratio was lower in group (1) than in group (2) and E/Em ratio was higher in group (1) than in group (2). Sm wave velocity was lower in group (1) than in group (2). From previous data and correlation of TDE finding with other echocardiographic data, we found that systolic and diastolic functions were impaired in patients of group (1) than in group (2) but Sm velocity and WMSI had higher sensitivity and higher specificity (94.7% sensitivity, 95.1% specificity for Sm wave velocity and 94.2% sensitivity, 90.2% specificity for WMSI). Conclusion From our study, we can conclude that TDE can be used for estimation of systolic and diastolic functions of LV and hence identification of patients at high risk for LV thrombus formation after first time acute anterior myocardial infarction and we recommend more studies to support our results about the importance of the role of oral anticoagulant after AMI.

Prevalence of cardiomyopathy in asymptomatic patients with left bundle branch block referred for cardiovascular magnetic resonance imaging

The diagnostic evaluation of patients with isolated left bundle branch block (LBBB) is challenging due to limitations of several non-invasive tests. Our aim was to evaluate the diagnostic value of cardiovascular magnetic resonance (CMR) in asymptomatic patients with LBBB. Sixty-one asymptomatic patients with complete LBBB who were referred for CMR from January 2005 to November 2010 were identified. 29 patients (18 men) had normal echocardiograms (echo) whereas 25 (18 men) had abnormal findings on echo. Six had no echo and one had poor echo windows, and these patients were excluded from further analysis. Patients with cardiac symptoms or known coronary artery disease at the time of referral were also excluded. Of the 29 patients with normal echo, 9 (31%) were found to have pathological findings on CMR. The most common abnormalities were dilated cardiomyopathy-DCM (n = 6, 21%) followed by left ventricular hypertrophy (n = 2, 7%). Of the 25 patients who had an abnormal echo, CMR confirmed the diagnosis in 19 (76%) and provided clinically relevant additional information in 13 (52%) subjects. Of these 13 patients, 9 (69%) had characteristic patterns of myocardial late gadolinium enhancement (8 mid-wall and 1 patchy distribution consistent with DCM and cardiac sarcoid, respectively). CMR detects sub-clinical cardiomyopathy in a third of asymptomatic patients with LBBB despite normal echocardiograms. In those with abnormal echocardiograms, CMR provides additional clinically relevant information in over 50% of patients, including a high prevalence of mid-wall fibrosis in patients with impaired left ventricular function. These findings support the use of CMR as a valuable adjunct to conventional investigations in asymptomatic LBBB.