Preoperative Transthoracic Echocardiography Research Articles

Factors affecting adherence to recommendations on pre-operative cardiac testing: A cohort study.

Cardiac risk evaluation prior to noncardiac surgery is fundamental to tailor peri-operative management to patient's estimated risk. Data on the degree of adherence to guidelines in patients at cardiovascular risk in Europe and factors influencing adherence are underexplored. The aim of this analysis was to describe the degree of adherence to [2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines] recommendations on rest echocardiography [transthoracic echocardiography (TTE)] and to stress imaging prior to noncardiac surgery in a large European sample and to assess factors potentially affecting adherence. Secondary analysis of a multicentre, international, prospective cohort study (MET-REPAIR). Twenty-five European centres of all levels of care that enrolled patients between 2017 and 2020. With elevated cardiovascular risk undergoing in-hospital elective, noncardiac surgery. (Non)adherence to each pre-operative TTE and stress imaging recommendations classified as guideline-adherent, overuse and underuse. We performed descriptive analysis. To explore the impact of patients' sex, age, geographical region, and hospital teaching status, we conducted multivariate multinominal regression analysis. Out of 15 983 patients, 15 529 were analysed (61% men, mean age 72 ± 8 years). Overuse (conduction in spite of class III) and underuse (nonconduction in spite of class I recommendation) for pre-operative TTE amounted to 16.6% (2542/15 344) and 6.6% (1015/15 344), respectively. Stress imaging overuse and underuse amounted to 1.7% (241/14 202) and 0.4% (52/14 202) respectively. Male sex, some age categories and some geographical regions were significantly associated with TTE overuse. Male sex and some regions were also associated with TTE underuse. Age and regions were associated with overuse of stress imaging. Male sex, age, and some regions were associated with stress imaging underuse. Adherence to pre-operative stress imaging recommendation was high. In contrast, adherence to TTE recommendations was moderate. Both patients' and geographical factors affected adherence to joint ESC/ESA guidelines. NCT03016936.

Outcomes of maze procedure and mitral valve surgery in atrial functional mitral regurgitation: a retrospective study

BackgroundAtrial functional mitral regurgitation (AFMR) is a newly discovered condition associated with longstanding atrial fibrillation. This retrospective study aimed to analyze the outcomes of the maze procedure and mitral regurgitation (MR) surgery in AFMR and atrial fibrillation in comparison with those in degenerative MR (DMR).MethodsPatients who underwent mitral valve repair/replacement with a maze procedure at a hospital (July 2012–August 2021) were included. We excluded patients aged below 18 years undergoing concomitant coronary artery bypass grafting or atrial septal defect repair and those with MR etiology other than ARMR or DMR.ResultsWe included 35 patients with AFMR and 50 patients with DMR. Patient characteristics and postoperative outcomes were not significantly different between the two groups. Long-term outcomes revealed no significant differences in the ratio of cardiac mortality, stroke, or hospital readmission. However, after the maze procedure, the sinus rhythm restoration rate was significantly lower (62% vs. 28.5%, p < 0.001), a junctional rhythm state (p < 0.001) and permanent pacemaker insertion for sick sinus syndrome (SSS) (p = 0.03) were significantly more common in AFMR than DMR. On postoperative transthoracic echocardiography (TTE), the pulmonary artery systolic pressure was significantly less decreased in the AFMR group than in the DMR group compared with that on preoperative TTE (p = 0.04).ConclusionsAFMR showed excellent mitral valve surgery outcomes, similar to DMR, but had a significantly higher risk of pacemaker insertion for SSS after the maze procedure.

A Case of Transmural Lipoma of the Right Atrium

Primary cardiac tumors are a relatively rare disease. About 75% of primary cardiac tumors are benign. The most common histological type is myxoma, followed by cardiac fibroma, lipoma, etc. We report a case of a 53-year-old female patient admitted to the hospital due to &amp;quot;repeated palpitations and tightness of breath for 5 years, worsened for 2 days.&amp;quot; Preoperative transthoracic echocardiography revealed a hypoechoic mass approximately 3.1 cm x 3.0 cm in size within the right atrium, suggesting an intracardiac mass: nature? Chest computed tomography (CT) indicated a fat-density nodule within the right atrium, with a larger cross-sectional size of about 3.0 cm x 2.5 cm, suggesting a lipoma. The patient underwent excision of the right atrial mass under cardiopulmonary bypass. Intraoperative transesophageal echocardiography (TEE) revealed a mass within the right atrium, closely connected to the atrial wall, with no signs of tricuspid valve obstruction. Exploration during surgery revealed a yellow, smooth-surfaced mass approximately 3.0 cm x 3.0 cm in size, penetrating the right atrial wall, from which the mass and an additional 2mm margin of the right atrial wall were completely excised. A suitable-sized bovine pericardial patch was used to repair the defect in the right atrial wall. Postoperative TEE showed the disappearance of the right atrial mass. The postoperative pathological result indicated a lipoma. Cardiac lipoma is a rare benign primary cardiac tumor. The common sites of occurrence of this tumor are the right atrium, left ventricle, and pericardium. Based on their location, cardiac lipomas can be divided into three types: subepicardial, intramyocardial, and subendocardial lipomas, with subendocardial lipomas being the most common, accounting for over 50% of primary cardiac lipomas. Clinical symptoms largely depend on the size and growth location of the tumor, and it is generally believed that most cardiac lipomas are asymptomatic. Symptomatic lipomas can be treated with curative surgical excision. Transmural lipomas of the right atrium are relatively rare, and such lipomas may affect adjacent structures both inside and outside the atrial wall. Although the lipoma in this case did not significantly affect valve function or blood flow, the patient experienced repeated symptoms of palpitations and tightness of breath. Despite being a benign tumor, the lipoma in this case exhibited transmural growth within the right atrium, showing a certain degree of invasiveness, making surgical excision an effective treatment method.

Left atrial strain predicts the rhythm outcome in patients with persistent atrial fibrillation undergoing left atrial cryoablation during minimally invasive mitral valve repair.

Patients with atrial fibrillation (AF) have lower left atrial (LA) strain, which is a predictor for LA function. Here, we evaluated the prognostic value of LA strain to predict the rhythm outcome in patients with persistent AF undergoing LA cryoablation concomitant to minimally invasive mitral valve repair. Between 01/2016 and 12/2020, 72 patients with persistent AF underwent LA cryoablation during minimally invasive mitral valve surgery. All patients received a complete LA lesion set and left atrial appendage (LAA) closure with a clip. All patients received preoperative transthoracic echocardiography (TTE) with LA and left ventricular strain measurements. Preoperative LA and LV strain analysis was correlated with postoperative rhythm outcome. The mean age of the patients was 66.9 ± 7.2 years, of whom 42 (58%) were male patients. No major ablation-related complications occurred in any of the patients. Successful LAA closure was confirmed by intraoperative echocardiography in all patients. The 1-year survival rate was 97%. Freedom from AF at 12 months was 72% and 68% off antiarrhythmic drugs. Preoperative LA strain values were statistically significantly higher in patients with freedom from AF at 12 months of follow-up (12.7% ± 6.9% vs. 4.9% ± 4.1%, p = 0.006). Preoperative LV strain value was not associated with postoperative rhythm outcome. In multivariate logistic regression analysis, LA strain (p < 0.001) and AF duration (p = 0.017) were predictors for freedom from AF at 12 months of follow-up. In our study, LA strain analysis predicted the rhythm outcome in patients with persistent AF undergoing concomitant surgical AF ablation. In the future, LA strain might be a useful tool to guide decision-making on ablation strategies in patients with persistent AF.

Clinical Predictors of Device-Detected Atrial Fibrillation During 2.5 Years After Cardiac Surgery: Prospective RACE V Cohort

BackgroundPostoperative atrial fibrillation (POAF) is a frequent complication after cardiac surgery that is associated with late atrial fibrillation (AF) recurrences (late-POAF) and increased morbidity and long-term mortality. ObjectivesThis study sought to determine device-detected POAF incidence and to identify clinical variables associated with POAF, both in patients with and without preoperative AF history. MethodsA total of 133 consecutive patients undergoing cardiac surgery were prospectively enrolled and continuously monitored with an implantable loop recorder for 2.5 years after surgery. Preoperative transthoracic echocardiography, 12-lead electrocardiogram, blood biomarkers, and clinical data were analyzed to develop prediction models for early- and late-POAF. ResultsIn patients without preoperative AF history, early-POAF within the first 90 postoperative days occurred in 41 (47.1%) of 87 patients. Late-POAF after the first 90 postoperative days occurred in 22 (25%) of 87 patients, and 20 of these patients also had early-POAF during the first 90 days (20 of 22 [91%]). Increased right atrial minimum volume indexed for body surface area (RAVImin) and early-POAF were independently associated with late-POAF. A prediction model for late-POAF, which included RAVImin >11 mL/m2, age >65 years, and early-POAF, achieved an area under the curve of 0.82 (95% CI: 0.72-0.92). For patients with preoperative AF-history, late-POAF recurrences were frequent (22 of 33 [67%]). Increased RAVImin was independently associated with a higher incidence of late-POAF. ConclusionsIn patients with and without AF history, late-POAF recurrences are frequent, including in patients undergoing surgical AF ablation. In patients with no history of AF, late-POAF might be predicted with excellent accuracy by using a combination of preoperative variables. In patients with a history of AF, signs of advanced AF substrate (eg, increased right atrial volumes) were associated with long-term AF recurrences. [Reappraisal of Atrial Fibrillation: Interaction Between Hypercoagulability, Electrical Remodeling, and Vascular Destabilisation in the Progression of AF; NCT03124576]

Off-pump minimally invasive coronary artery bypass grafting in patients with left ventricular dysfunction: the lampang experience.

The minimally invasive cardiac surgery off-pump coronary artery bypass (MICSOPCAB) is technically difficult; therefore, previous studies have indicated that MICSOPCAB should be contraindicated in patients with impaired left ventricular (LV) function. In this study, we investigated the feasibility of MICSOPCAB in patients with impaired LV function. The 226 patients underwent MICSOPCAB between August 2017 and September 2022. Our study defined impaired LV function as ejection fraction (EF) in echocardiography 40% or less. The patients were divided into Low EF group (n = 39) and Normal EF group (n = 187). The Low EF group was in a more critical preoperative condition than Normal EF group (41.0% in the Low EF group vs. 14.4% in the Normal EF group; p < 0.001). For preoperative transthoracic echocardiography, LV end-diastolic diameter (5.5 ± 0.9 cm in the Low EF group vs. 5.0 ± 0.8 cm in the Normal EF group; p < 0.001) and LV end-systolic diameter (4.4 ± 1.0 cm in the Low EF group vs. 3.4 ± 1.0 cm in the Normal EF group; p < 0.001) were significantly larger in the Low EF group. No differences were found in the operative time (180 [160-240] min in the Low EF group vs. 205 [165-253] min in the Normal EF group; p = 0.231) and the median number of distal anastomoses (2 [1-2] in the Low EF group vs. 2 [1-3] in the Normal EF group; p = 0.073). Intensive care unit stay was longer in the Low EF group than in the Normal EF group (2 [1-2] in the Low EF group vs. 1 [1-2] in the Normal EF group; p = 0.010). Perioperative transfusion was more common in the Low EF group than in the Normal EF group (69.7% vs. 49.2%; p = 0.023). There were no differences in major complications, hospital stay, and 30-day mortality. The Kaplan-Meier curve showed no significant difference in postoperative major adverse cardiac or cerebrovascular events rates between the two groups (p = 0.185). In this study, MICSOPCAB can be performed in patients with low EF having short- and mid-term outcomes similar to patients with normal EF. Therefore, low EF should not be contraindicated in MICSOPCAB.

Left atrial myxoma with mitral valve prolapse detected on preoperative transthoracic echocardiography by a perioperative ultrasonographer: A case report

Left atrial myxoma with mitral valve prolapse detected on preoperative transthoracic echocardiography by a perioperative ultrasonographer: A case report

Enhancing predictive accuracy of the cardiac risk score in open abdominal aortic surgery: the role of left ventricular wall motion abnormalities.

Open abdominal aortic surgery carries many potential complications, with cardiac adverse events being the most significant concern. The Vascular Study Group Cardiac Risk Index (VSG-CRI) is a commonly used tool for predicting severe cardiac complications and guiding clinical decision-making. However, despite the potential prognostic significance of left ventricular wall motion abnormalities (LVWMAs) and reduced LV ejection fraction (LVEF) for adverse outcomes, the VSG-CRI model has not accounted for them. Hence, the main objective of this study was to analyze the added value of LV wall motion on the discriminatory power of the modified VSG-CRI in predicting major postoperative cardiac complications. A prospective study was conducted involving 271 patients who underwent elective abdominal aortic surgery between 2019 and 2021. VSG-CRI scores were calculated, and preoperative transthoracic echocardiography was conducted for all patients. Subsequently, a modified version of the VSG-CRI, accounting for reduced LVEF and LVWMAs, was developed and incorporated into the dataset. The postoperative incidence of the composite endpoint of major adverse cardiac events (MACEs), including myocardial infarction, clinically relevant arrhythmias treated with medicaments or by cardioversion, or congestive heart failure, was assessed at discharge from the index hospitalization, with adjudicators blinded to events. The predictive accuracy of both the original and modified VSG-CRI was assessed using C-Statistics. In total, 61 patients (22.5%) experienced MACEs. Among these patients, a significantly higher proportion had preoperative LVWMAs compared to those without (62.3% vs. 32.9%, p < 0.001). Multivariable regression analysis revealed the VSG-CRI [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.21-1.77; p < 0.001] and LVWMA (OR 2.76; 95% CI 1.46-5.23; p = 0.002) as independent predictors of MACEs. Additionally, the modified VSG-CRI model demonstrated superior predictability compared to the baseline VSG-CRI model, suggesting an improved predictive performance for anticipating MACEs following abdominal aortic surgery [area under the curve (AUC) 0.74; 95% CI 0.68-0.81 vs. AUC 0.70; 95% CI 0.63-0.77; respectively]. The findings of this study suggest that incorporating preoperative echocardiography can enhance the predictive accuracy of the VSG-CRI for predicting MACEs after open abdominal aortic surgery. Before its implementation in clinical settings, external validation is necessary to confirm the generalizability of this newly developed predictive model across different populations.

Aortic valve leaflets are asymmetric and correlated with the origin of coronary arteries.

Asymmetry of the aortic valve leaflets has been known since Leonardo Da Vinci, but the relationship between size and shape and origin of the coronary arteries has never been examined. Our aim was to evaluate this anatomy in a population of pediatric patients using a cross-sectional study design. Consecutive pediatric patients with trans-esophageal echocardiography (TEE), with or without trans-thoracic echocardiography (TTE), were included in our study. Exclusion criteria: (I) bicuspid aortic valve; (II) aortic valve stenosis; (III) hypoplasia of aortic valve annulus, or aortic root; (IV) truncal valve; (V) coronary artery atresia; (VI) previous surgery on aortic valve and/or coronary arteries. In pre-operative TTE and intra-operative TEE inter-commissural distance and length of aortic valve leaflets were measured in short axis view in the isovolumic phase of systole. Echocardiography investigations, anonymized and randomly coded, were independently reviewed by at least two readers. Echocardiography, angiography, cardiac computed tomography (CT) scan and magnetic resonance imaging (MRI), and operative notes were reviewed to identify origin of coronary arteries. Two hundred sixty-one pediatric patients were identified, 93 excluded per our criteria, leaving 168 patients, age 2.6±4.3 years, weight 12.87±17.34 kg, 128 (76%) with normal and 40 (24%) with abnormal coronary arteries. In TTE and TEE measurements the non-coronary leaflet had larger area (P<0.001), while the right and left had equal areas, but different shape, with the left leaflet longer (P<0.001) and narrower (P=0.005) than the right. With the major source of blood flow from the right coronary sinus, the non-coronary leaflet was still the longest. However, there was no statically significant difference between the size and shape previously observed between the right and left leaflets. Our study showed asymmetry of size and shape among aortic valve leaflets, and a relationship with coronary artery origin. The complex aortic root anatomy must be approximated to optimize function of any surgical repair. These findings also may prove useful in the pre-operative definition of coronary artery anatomy and in the recognition of coronary artery anomalies.

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

Is myocardial fibrosis appropriately assessed by 2D strain derived integrated backscatter?

Abstract Introduction Calibrated integrated backscatter (cIB) may be obtained from bidimensional (2D) strain echocardiography as a quantification measurement of myocardial ultrasound reflectivity. Increased collagen content of the myocardium modifies tissue reflectivity and cIB is suggested as a marker of left ventricular (LV) fibrosis. However, its diagnostic accuracy is not fully established. Aim To assess the correlation between cIB by 2D strain and LV myocardial fibrosis (MF), as evaluated by non-invasive imaging and histopathology. Methods Correlation study from a cohort of 157 patients with severe symptomatic aortic stenosis (AS) referred for surgical aortic valve replacement (AVR). Patients with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of AVR were selected. Two groups of 30 patients were evaluated, with and without late gadolinium enhancement (LGE) at CMR. Integrated Backscatter was obtained at QRS peak in decibels (dB) from both parasternal long axis (PLAX) and apical-three-chamber (A3C) cine clips at Qanalysis. cIB was calculated by subtracting the pericardial intensity from the average of the anteroseptal and basal inferolateral wall values. Correlation analysis was performed for the whole group of patients with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) from Masson´s Trichrome staining. IBS values were compared in both group of patients. Results 60 patients (74 [36-74] years, 45% male) with high gradient (mean gradient: 63±20mmHg), normal flow (45±10mL/m2), preserved ejection fraction (60±9%) AS were included. Basal septal cIB was –9.17±9.45dB and –17.45 (–31.2–10.95) dB from A3C and PLAX views, respectively. These indexes did not correlate with basal septum thickness or global LV mass. Absolute and cIB did not correlate neither with global and regional T1 and ECV values, nor with CVF at EMB. These were not significantly different in both groups of patients and there was no correlation between cIB values and mass of replacement MF in patients with LGE. Conclusion In these cohort of patients with classical severe AS, there was no correlation of cIB with imaging markers of both replacement and diffuse MF. cIB also didn´t correlate with CVF at histopathology. These findings suggest that reflectivity indexes are not suitable for myocardial tissue characterization in this setting.

Abstract 12499: The Incidence and Predictor of Persistent Iatrogenic Atrial Septal Defect in Patients Who Underwent Catheter Ablation

Background: The left atrium approach for atrial fibrillation (AF) ablation requires an atrial transseptal puncture that may cause an iatrogenic atrial septal defect (iASD). Aims: This study aims to investigate the incidence and predictor of iASD in patients who underwent catheter ablation. Methods: This retrospective study included 639 patients (489 male; 60.2 ± 10.7 years) who underwent initial catheter ablation for AF between May 2005 and June 2018. All patients received preoperative transesophageal echocardiography (pre-TEE), preoperative transthoracic echocardiography (pre-TTE), and TTE one day after the procedure (post-TTE). TTE 6 months after the procedure (6M-TTE) was performed in 533 patients. The iASD incidence after 6 months, pre-procedure characteristics, and methods were evaluated. Results: Patent foramen ovale (PFO) was diagnosed in 6.6% (42/639) using pre-TEE and detected in 26.2% (11/42) using pre-TTE. Of the 533 patients who underwent 6M-TTE, 497 had no PFO using pre-TEE. iASD was observed in 59.6% (296/497) using post-TTE and 4.6% (23/497) using 6M-TTE. In the multivariate analysis, the total diameter of sheath through the septum (OR 1.21, p &lt; 0.001) or two sheaths placed through a single puncture (OR 4.26, p = 0.001) was the independent risk factor on iASD incidence in 6M-TTE. iASD was more likely to occur in cryoballoon ablation using a larger sheath than radiofrequency catheter ablation. Conclusions: iASD was not a rare complication. A larger sheath diameter or two sheaths placed through a single puncture might be associated with the incidence of iASD. Careful procedural considerations might be required for patients with hemodynamic deterioration by iASD.

Echocardiographic diagnosis of rupture of mitral valve papillary muscle

ObjectiveTo explore the value of echocardiography in diagnosing papillary muscle rupture (PMR) of the mitral valve, and summarize the characteristic echocardiographic features of different types. MethodsEchocardiograms of 13 PMR patients confirmed by surgery in Wuhan Union Hospital between January 2009 and December 2022 were retrospectively analyzed and their preoperative transthoracic echocardiography (TTE) was compared with surgical findings. ResultsA total of 9020 patients underwent mitral valve repair or replacement surgery during the study period including 13 (0.14%) for PMR. Of the 13 PMRs, 8 cases were partial PMR(P-PMR), 5 cases were complete PMR(C-PMR); 3 cases were anterolateral PMR, and 10 were posteromedial PMR. The diagnostic accuracy, sensitivity, and specificity of the preoperative TTE were 99.9%, 53.8% and 99.9% respectively. Echocardiographic features of 10 patients (5-C-PMR and 5 P-PMR) with detailed TTE and intraoperative transesophageal echocardiography (TEE) data included: both anterior and posterior leaflets prolapse (C-PMR 60% vs P-PMR 60%); flail leaflet (C-PMR100% vs P-PMR 40%); All C-PMRs and P-PMRs have severe, eccentric and lateral regurgitation; flail attachment (chordae tendinae and ruptured PM) at the tip of prolapsed leaflet (C-PMR100% vs P-PMR 60%); high-echo masses resembled “champagne glasses” in 100% of the C-PMR; high-echo masses resembled “lotus-seedpod” in 60% and “dumbbell-shaped” torn PM in remaining 40% of the P-PMR. ConclusionsDifferent PMR subtypes have different echocardiographic characteristics. Combining TTE and TEE can accurately identify the typical features of PMR such as ipsilateral hemipetal leaflet prolapse, high-echoic mass at the tip of the leaflet, massive eccentricity and lateral regurgitation.

Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries.

Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.

Is myocardial fibrosis appropriately assessed by calibrated and 2D strain derived integrated backscatter?

AimsIncreased collagen content of the myocardium modifies tissue reflectivity and integrated backscatter (IBS) indexes are suggested as markers of myocardial fibrosis (MF). We sought to assess the correlation between calibrated (c) IBS and bidimensional (2D) strain derived IBS with left ventricular (LV) MF in patients with severe aortic stenosis (AS).Methods and resultsWe made a prospective observational cohort study including 157 patients with severe AS referred for surgical aortic valve replacement (AVR), with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of surgery. Two groups of 30 patients were specifically evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak from both parasternal long axis (PLAX) and apical-three-chamber (AP3C) views and measured in decibels (dB). Whole-cardiac cycle IBS at basal anterior septum was obtained from 2D longitudinal strain. Correlation analysis of reflectivity indexes was performed with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) (Masson´s Trichrome). IBS values were compared in both group of patients (LGE + vs. LGE –). 60 patients (74 [36–74] years, 45% male) with high gradient (mean gradient: 63 ± 20mmHg), normal flow (45 ± 10mL/m2) AS and preserved left ventricular ejection fraction (60 ± 9%) were included. Basal septum cIBS was − 17.45 (–31.2–10.95) and − 9.17 ± 9.45dB from PLAX and A3C views, respectively. No significant correlations were found between IBS and both non-invasive CMR tissue characterization and CVF: median MF of 9.7(2.1–79.9)%. Acoustic indexes were not significantly different according to the presence of pre-operative LGE.ConclusionIn this group of patients with classical severe AS, IBS reflectivity indexes are of no added value to discriminate the presence of MF.Graphical

Preoperative left ventricular diastolic dimension index is associated with outcomes after HeartMate 3 implantation.

We investigated the association between indexed left ventricular diastolic dimension and clinical outcomes after HeartMate 3 implantation. We retrospectively reviewed patients implanted with the HeartMate 3 at our centre between November 2014 and September 2021. Left ventricular diastolic dimension was assessed via preoperative transthoracic echocardiography and left ventricular diastolic dimension index was calculated as left ventricular diastolic dimension/body surface area. The primary outcome was a composite of death or readmission due to right heart failure or stroke. The cut-off left ventricular diastolic dimension index value most closely associated with outcomes was determined by receiver-operating characteristic curve and restricted cubic spline analyses. Left ventricular diastolic dimension index measurements were available for 252 of 253 (99.6%) patients. Using a left ventricular diastolic dimension index cut-off value of 33.5 mm/m2, the cohort was divided: left ventricular diastolic dimension index ≤ (n = 131) or > (n = 121) 33.5 mm/m2. While there were no significant differences in age, INTERMACS level and preoperative haemodynamics between groups, patients with smaller left ventricular diastolic dimension index were more likely to have a larger body surface area (2.1 vs 1.9 m2, P < 0.001), ischaemic cardiomyopathy [64 (49%) vs 40 (33%), P = 0.01] and smaller left atrium volume index [40.5 (32.3-54.0) ml/m2 vs 54.0 (43.0-66.8) ml/m2, P < 0.001]. Smaller left ventricular diastolic dimension index patients had significantly worse survival (74% vs 88%, log-rank P = 0.009) and freedom from adverse events (55% vs 73%, log-rank P = 0.005) at 3-year follow-up. Smaller left ventricular diastolic dimension index was independently associated with the composite outcome (Hazard ratio 2.24, P = 0.002). Smaller preoperative left ventricular diastolic dimension index is associated with worse outcomes in patients undergoing HeartMate 3 implantation.

Pitfalls in the Diagnosis of Peri-Operative Acute Pulmonary Embolism: A Case Report

An 80 years-old man with hypertension, atrial fibrillation, and coronary artery occlusion disease presented for an elective right femur bipolar hip arthroplasty under general anesthesia. Preoperative transthoracic echocardiography (TTE) showed only preexisting regional wall motion abnormality. During the reversal of muscular relaxation following surgery, there was a sudden decrease in blood pressure associated with rapid ventricular response, which was successfully treated by cardioversion. No decrease in end-tidal carbon dioxide level was observed during the hypotensive episode. However, despite fluid and blood resuscitation and vasopressor treatment, there was a repeated hemodynamic collapse postoperatively. A portable TTE showed dilated right atrium and right ventricle (RV), D-shaped left ventricle, and septal wall motion abnormalities consistent with RV pressure overload (McConnell’s sign). Computed tomography pulmonary angiography revealed multifocal PE (pulmonary embolism). Anticoagulation therapy was continued to avoid PE recurrence. The patient discharged uneventfully 30 days later. Perioperative PE is a rare and perhaps dangerous circumstance that can be challenging to diagnose when it happens under anesthesia. The likelihood of PE should always be suspected at the time of perioperative hemodynamic collapse.

Is myocardial fibrosis appropriately assessed by 2D strain derived integrated backscatter?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Calibrated integrated backscatter (cIBS) may be obtained from bidimensional (2D) strain echocardiography as a quantification measurement of myocardial ultrasound reflectivity. Increased collagen content of the myocardium modifies tissue reflectivity and cIBS is suggested as a marker of left ventricular (LV) fibrosis. However, its diagnostic accuracy is not established. Aim To assess the correlation between cIBS by 2D strain and LV myocardial fibrosis (MF), as evaluated by non-invasive imaging and histopathology. Methods Correlation study from a cohort of 157 patients with severe symptomatic aortic stenosis (AS) referred for surgical aortic valve replacement (AVR). Patients with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of AVR were selected. Two groups of 30 patients were evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak in decibels (dB) from both parasternal long axis (PLAX) and apical three chamber (A3C) cine clips at Qanalysis (Figure 1A). cIBS was calculated by subtracting the pericardial intensity from the average of the anteroseptal and basal inferolateral wall values. Correlation analysis was performed for the whole group of patients with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) from Masson´s Trichrome staining. IBS values were compared in both group of patients. Results 60 patients (73 [68–74] years, 45% male) with high gradient (mean gradient: 64±20mmHg), normal flow (45±10mL/m2), preserved ejection fraction (60±9%) AS. Basal septal cIBS was −9.2±9.5dB and −16.3±7.9dB from A3C and PLAX views, respectively. These indexes did not correlate with basal septum thickness or global LV mass. Absolute and cIBS did not correlate neither with global and regional T1 and ECV values, nor with CVF at EMB (Figure 1B). These were not significantly different in both groups of patients and there was no correlation between cIBS values and mass of replacement MF in patients with LGE. Conclusion In these cohort of patients with classical severe AS, there was no correlation of cIBS with imaging markers of both replacement and diffuse MF. cIBS also didn´t correlate with CVF at histopathology. These findings suggest that reflectivity indexes are not suitable for myocardial tissue characterization in this setting.

The Early Effects on Tricuspid Annulus and Right Chambers Dimensions in Successful Tricuspid Valve Bicuspidization.

It is unclear to what degree of tricuspid annulus (TA) reduction is necessary to achieve good postoperative results in surgical bicuspidization. The study aimed to evaluate TA and right heart chamber's dimensions before and after heart surgery; and to compare TA parameters assessed by different modalities. Forty patients underwent mitral valve surgery with or without concomitant tricuspid valve (TV) bicuspidization. Preoperative and postoperative measurements of TA dimensions were performed prospectively using two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography (TTE). Additionally, preoperative transesophageal echocardiography (TOE) was performed in the operating room prior to surgery. All patients had no or mild TR immediately after surgery. There was a significant reduction in 2D and 3D parameters of the TV and right chambers in the TV bicuspidization group. However, TV leaflets' tethering parameters did not change significantly. Preoperative 3D TTE measurements were smaller than those obtained through 3D TOE in the operation room, before surgery under general anesthesia. The 2D systolic apical 4Ch diameter and the parasternal short axis diameter mainly represent the 3D minor axis of the TA and are smaller than its 3D major axis. Although bicuspidization results in a one-third reduction of the TV area, tethering of the TV leaflets remains unchanged. Moreover, 3D TOE parameters of the TV under general anesthesia are larger than preoperative 3D TTE measurements. Conventional 2D measurements are insufficient for evaluating the maximum diameter of the TA.

Atrial contractile and electrical remodeling is associated with more complex conduction patterns in patients without history of atrial fibrillation: a high-density epicardial mapping study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by the Netherlands Heart Foundation (CVON2014-09, RACE V Reappraisal of Atrial Fibrillation: Interaction between hyperCoagulability, Electrical remodelling, and Vascular Destabilisation in the Progression of AF), the European Union (ITN Network Personalized Therapies for Atrial Fibrillation: a translational network: PersonalizeAF, grant 860974, CATCH ME: Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly, No. 633196). Background Early atrial remodeling refers to a concept where atrial structural, functional, and electrophysiological changes may be present without clinical manifestation of atrial arrhythmias. (1) However, it is currently unknown how electrophysiological and functional atrial properties are related, especially in the early stages of atrial remodeling. Purpose To investigate the relationship between electrophysiological properties of the atria, determined by intraoperative high-density epicardial mapping after AF-induction, and echocardiographic and electrocardiographic parameters in patients without a history of AF undergoing cardiac surgery. Methods All patients underwent functional and electrophysiological analysis of both atria using preoperative transthoracic echocardiography, electrocardiography, and intraoperative biatrial high-density epicardial mapping. Postoperatively, all patients were continuously monitored for occurrence of new-onset postoperative AF (POAF). In addition to univariable and multivariable analysis, cluster analysis was performed to identify distinct clusters of subjects for epicardial mapping parameters. Results The study population consisted of 38 patients undergoing coronary artery bypass grafting, isolated aortic valve replacement, or the combination of both. All patients completed 1-year continuous rhythm monitoring and 19 patients (50%) developed POAF. There was a greater number of waves/cycle (4.57±1.55 vs. 3.98±1.63, p=0.04) and breakthrough (BT) waves/cycle (1.16±0.58 vs. 0.88±0.60, p=0.01) in the RA compared to the LA (Figure 1). Also, there was a lower conduction velocity (CV) in the RA than in the LA (0.71±0.10m/s vs 1.19±0.36m/s, p&amp;lt;0.01) (Figure 1). Average waves/cycle were significantly correlated with reduced P-wave duration and P-wave amplitude (Spearman’s rho=-0.32, p=0.04, and Spearman’s rho=-0.32, p=0.04, respectively). Also, there was significant negative correlation between LA booster function and LA waves/cycle (Spearman’s rho=-0.55, p&amp;lt;0.01). Survival analysis revealed that older age, lower P-wave amplitude, reduced LA booster function, and increased RA waves/cycle were associated with increased occurrence of POAF (Figure 2). Cluster analysis was performed for RA and LA epicardial mapping parameters, which identified 2 distinct clusters: cluster 1 consisted of patients with more complex atrial electrical conduction patterns, and cluster 2 less complex atrial electrical conduction patterns. Multivariable analysis showed that reduced LA booster function was independently associated with a cluster representing more complex atrial electrical conduction patterns in the LA (OR=1.13, 95% CI: 1.02-1.25, p=0.02). Conclusion In patients without a history of AF, reduced LA contractile function and lower P-wave amplitude are associated with more complex electrical conduction patterns in acutely induced AF, potentially representing an early step in the atrial remodeling process.